Episode 4.07 Alcohol and substance misuse

November 6, 2017

Presented by:

Dr Iain Wilkinson (Consultant Geriatrician East Surrey Hospital)

Dr Jo Preston  (Consultant Geriatrician St George’s Hospital)

 

Sip of MDTea

 

Sip of MDTea (pdf here)

Broadcast date: 7th November 2017

 

 

 

 

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Episode 4.7 Show Notes – Alcohol and older people (pdf here)

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Learning Outcomes

 

Knowledge:

  • To understand  the growing problem of drinking and substance misuse within the elderly population

Skills:

  • To identify alcohol abuse and substance misuse
  • To help staff learn how to engage in constructive dialogue with older people experiencing substance misuse in ways that can bring about positive change

Attitudes:

  • To understand how alcohol affects the ageing body
  • To understand how older people may view alcohol and  abused substances and why this is a growing problem.

Definitions:

***Nerd alert***

Alcohol addiction definition from DSM 5

Addiction (termed substance dependence by the American Psychiatric Association) is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring any time in the same 12-month period:

  1. Tolerance: (a) A need for markedly increased amounts of the substance to achieve intoxication or the desired effect or (b) Markedly diminished effect with continued use of the same amount of the substance.
  2. Withdrawal,
  3. The substance is often taken in larger amounts or over a longer period than intended.
  4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.
  5. A great deal of time is spent in activities necessary to obtain the substance (such as visiting multiple doctors or driving long distances), use the substance (for example, chain-smoking), or recover from its effects.
  6. Important social, occupational, or recreational activities are given up or reduced because of substance use.
  7. The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance (for example, current cocaine use despite recognition of cocaine-induced depression or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

 

Early onset alcoholism. This term is typically used to describe people who have a life-long pattern of alcoholism. People in this group have suffered from alcoholism for most of their lifetime. These people are most likely to suffer from poor relationships with family, a decline in socio-economic status and a history of alcohol abuse in the family. Experts believe around 75% of elderly people suffering from alcoholism sit in this category.

Late onset alcoholism. Many of these people begin to suffer from alcoholism much later in life, typically during their 40s or 50s. Many of these people are highly educated and have attained a high socio-economic status. These people often suffer from alcoholism due to some traumatic event they have suffered from during their lives. C. 30%

http://www.rehab-recovery.co.uk/

Or 3 types:

  • Survivors (early onset drunk all their lives},
  • Reactors (due to traumatic events later in life) and
  • Intermediate (binge, started later and can be helped easily with supportive measures

 

Size of the problem

Difficult to really know – probably a lot higher than we expect or think.

Older people tend to drink less alcohol than younger people, but even so 1 in 5 older men and 1 in 10 older women are drinking enough to harm themselves. These figures have increased by 40 per cent in men and 100 per cent in women over the past 20 years.

RCPsyh Website

Really useful resources:

From the RCPsych – Invisible addicts and the substance missuse guide in older adults. And from the USA the NCBI Substance Abuse Among Older Adults. Links to all these in the show notes.

 

One study (259 ppl in Philidelphia) published this year of city dwelling adults showed: Alcohol or substance abuse was reported by over 20% of respondents, with 3.4% of respondents engaged in maladaptive alcohol use. Alcohol use was predictive of depression, global psychological distress, and decreased quality of life.

Loscalzo et al. (2017) Alcohol and other drug use in older adults: results from a community needs assessment. Aging Clin Exp Res. 2017 Feb 8.

 

  • “Safe” levels are considered to be females 14 units per week and  males 21 units.
  • RCP have reported 1 in 6 males and 1 in 15 females over 65 are drinking at harmful levels.
  • There has been a rise of 60% in older males but 100% in older females  over a 16 year  period, 1990-2006.

Older People and substance use: the nurse’s role. Nursing in Practice

  • Mortality rates linked to drug and alcohol use are higher in older people compared with younger people.
  • Older people may show complex patterns and combinations of substance use (e.g. alcohol plus inappropriate use of prescribed medications)
  • Older people use large amounts of prescription and over-the-counter medication and rates of misuse (both intentional and inadvertent) are high, particularly in older women  
  • Although alcohol use does decline with age, a significant number of older people consume alcohol at dangerous levels  
  • Although illicit drug use is uncommon in the over-65 age group at present, there have already been significant increases in the over- 40 age group. As this cohort ages we should anticipate a significant increase in the number of older people using illicit drugs
  • Older men are at greater risk of developing alcohol and illicit substance use problems than older women. However, older women have a higher risk of developing problems related to the misuse of prescribed and over-the-counter medications
  • Among older people, psychosocial factors (including bereavement, retirement, boredom, loneliness, homelessness and depression) are all associated with higher rates of alcohol use  
  • Because of physiological changes associated with ageing, older people are at increased risk of adverse physical effects of substance misuse, even at relatively modest levels of intake

Invisible Addicts

  • Only 6–7% of high-risk people with substance misuse problems over 60 years of age receive the treatment that they require.
  • Older people are less likely to complain of substance misuse problem but are more likely to be motivated to recover cf with younger people. Older people are more often in contact with Health and social care professionals so we have opportunities to start the abstinence process and hence recovery.

Substance misuse in older people – a guide from RCPsyh

 

How to assess – general approach

    1. Take a history – Underreporting may occur because of denial, stigma, lack of awareness or memory impairment.
      1. Assessment will lead to a formulation and management plan that takes into account multiple comorbidities, functional abilities, the influence of loss events on mood state,  cognitive state (including the influence of substances and physical disorders) and social support. Multiple assessments are often required to build up a clinical picture, including the need for vigilance about safeguarding.
    2. Systematic assessment – thinking about what drink – when, where, how do they access it, previous mental health problems, falls etc etc
    3. Screening
      1. CAGE is ok but a bit insensitive.
      2. Short Michigan Alcoholism Screening Test – Geriatric version (SMAST-G; Blow et al, 1998), has been validated for use in older hospital in-patients

 

  • General practitioners should screen every person over 65 years of age for substance misuse as part of a routine health check, using specific tools such as the Short Michigan Alcoholism Screening Test – Geriatric version (SMAST-G); screening should also incorporate cognitive testing using tools such as the Mini-Mental State Examination (MMSE)  Re-screening should be carried out if certain physical and/or psychological symptoms are present or if the person is experiencing major life events.

 

Invisible Addicts

  1. Examination
  2. Formulation of a management plan – we will look at this later

Or think about using the 5 A’s approach: (assess, advise, agree, assist and arrange) as a useful guide to practice

 

There are considerable opportunities for GPs to improve the quality of life for older people with alcohol misuse. This can be achieved by the use of both planned and opportunistic screening as part of a general health review, particularly when accompanied by mental disorders, as well as coexisting alcohol-related physical problems. Improving referral to secondary care services will also help provide a seamless approach to improving care for an older population that will continue to weigh heavily on primary care.

Rahul Rao, Ilana B Crome and Peter Crome (2016)  Managing older people’s alcohol misuse in primary care

Br J Gen Pract;  66 (642): 6-7.

 

Why Does Alcoholism in the Elderly Go Undetected?

 

  • Over the last 100 years, our society has increasingly moved elderly people out of the center of social and familial interaction, typically into retirement homes or nursing homes. This means that there are far fewer individuals around consistently to recognize the symptoms of elderly alcoholism. Social isolation – link to loneliness EP later in series.
  • Additionally, unlike youthful binge drinkers, seniors don’t usually have legal troubles associated with indulging because many do not drive or get into bar fights (for example). At retirement age few seniors face unemployment due to drinking. This means it’s much easier to excuse odd behavior as just old age quirks. Nothing immediately sends up warning flags to family and professionals alike.
  • Even when family gets called in due to a health problem or injury, it’s not always evident that alcohol abuse is to blame.

Cost Effectiveness

  • “Treating people with alcohol use disorders is cost-effective. For every £1 spent on treatment, the public sector saves £5.”

 

Health promotion Interventions

Alcohol and substance misuse is misunderstood in the elderly population and is on the increase due to many social factors.  More training for health professionals in contact with this complex cohort is a must as the cost implications to the NHS would be favourable as well as the outcome on a patient to patient basis.

 Women, Ethnicity and Empowerment in Later Life, Haleh Afshar, Myfanwy Franks and Mary Maynard, ESRC, 2002

Problems  with alcohol

  1. Falling and injuryies
  2. Admission to hospital up to 40% of admissions to US hospitals in the elderly associated with alcohol (but elderly in this context was >40yrs!!)
  3. Social isolation, depression and other mental health problems
  4. Drug interactions – one study looks specifically at this.
  • This study was a cross-sectional assessment of a stratified random sample of 2100 elderly people (  65 years) in Espoo, Finland.
  • The response rate was 71.6% from the community-dwelling sample.
    • Drugs were coded according to their Anatomical Therapeutic Chemical (ATC) classification index (ATC DDD 2012). Significant alcohol interactive (AI) drugs were examined
    • Participants splint into at risk, moderate risk and minimal or non ETOH users.
  • Of the total sample (n  1395), 1142 respondents responded as using at least one drug.
    • Of the drug users, 715 (62.6%) persons used alcohol.
    • “ at-risk users mean was – 4.2 medications
    • Moderate users –  4.0 (SD 2.6)
    • Minimal / non users – 5.4 (SD 3.4) (p  0.001).
  • The concomitant use of AI drugs was widespread.
    • Among the At-risk users = 42.2% , moderate users = 34.9% , and  minimal/nonusers = 52.7% (p  0.001).
    • One in 10 of “ at-risk users ” used warfarin, hypnotics/sedatives, or metformin.
  • Conclusions . Use of AI drugs is common among older adults, and this increases the potential risks related to the use of alcohol.

 

Protection from alcohol?

A study from 2007 published in age and ageing shows:  in middle-aged and older men and women, moderate levels of alcohol consumption are associated with better cognitive health than abstinence.

Lang et al (2007)  Moderate alcohol consumption in older adults is associated with better cognition and well-being than abstinence.Age Ageing. May;36(3):256-61.

 

  • As part of the Cardiovascular Health Study, 3660 adults aged 65 years and older underwent MRI of the brain from 1992 to 1994. Participants were excluded with a confirmed history of cerebrovascular disease.
  • Self-reported intake of beer, wine, and liquor at the annual clinic visit closest to the date of the MRI and grouped participants into 6 categories: abstainers, former drinkers, ,1 drink weekly, 1 to ,7 drinks weekly, 7 to ,15 drinks weekly, and >15 drinks weekly.
  • Neuroradiologists assessed MRIs and used multivariate regression to control for sociodemographic and clinical characteristics.
  • Results—We found a U-shaped relationship between alcohol consumption and white matter abnormalities.
  • Conclusions— Moderate alcohol consumption is associated with a lower prevalence of white matter abnormalities and infarcts, thought to be of vascular origin, but with a dose-dependent higher prevalence of brain atrophy on MRI among older adults. The extent to which these competing associations influence overall brain function will require further study

Mukamal et al (2001) Alcohol Consumption and Subclinical Findings on Magnetic Resonance Imaging of the Brain in Older Adults The Cardiovascular Health Study Stroke. 2001;32:1939-1946.

How this happens is not really clear but might be related to reduced inflammation.

  • A study of over 3000 older men from italy. Alcohol intake showed a J-shaped relationship with mean IL-6 (P for quadratic term <0.001) and CRP (P=0.014) levels.
  • The association was consistent in both men and women.
  • Compared with subjects who consumed 1 to 7 drinks per week, those who never drank had an increased likelihood of having high levels of both IL-6 and CRP, as did those who drank 8 or more drinks per week.
  • No relationship between alcohol intake and levels of TNF-alpha and PAI-1 (P=0.137 and 0.08, respectively).
  • Conclusions In well-functioning older persons, light alcohol consumption is associated with lower levels of IL-6 and CRP. These results might suggest an additional biological explanation to the epidemiological link between moderate alcohol consumption and cardiovascular events.

Valpato et al (2004) Relationship of alcohol intake with inflammatory markers and plasminogen activator inhibitor-1 in well-functioning older adults: the Health, Aging, and Body Composition study. Circulation. Feb 10;109(5):607-12.

Both moderate drinking and the MDP (mediterranean drinking pattern) were associated with a lower risk of falls and injurious falls in older adults. However, sound advice on alcohol consumption should balance risks and benefits.

Ortola (2017) Patterns of alcohol consumption and risk of falls in older adults: a prospective cohort study

Osteoporos Int. 2017 Jul 19.

How to stop?

Brief interventions work and we can all do these:

Follows the FRAMES format:

  • Feedback: give structured and personalised feedback on risk and harm.
  • Responsibility: place the emphasis on the patient’s personal responsibility for change.
  • Advice: give advice to the patient on making a change in drinking habits.
  • Menu: provide a menu of strategies for making a change.
  • Empathy: use an empathic and non- judgemental approach.
  • Self-efficacy: attempt to increase the patient’s confidence in being able to change behavior.

Substance misuse in older people – a guide from RCPsyh

 

A study compared 5-year treatment outcomes of older adults to those of middle-aged and younger adults in a large managed care chemical dependency program.

    • Older adults were less likely to be drug-dependent at baseline than younger and middle-aged adults, and had longer retention in treatment than younger adults.
    • At 5 years, older adults were less likely than younger adults to have close family or friends who encouraged alcohol or drug use.
    • Fifty-two per cent of older adults reported total abstinence from alcohol and drugs in the previous 30 days versus 40% of younger adults.
    • Older women had higher 30-day abstinence than older men or younger women.
    • Among participants dependent only on alcohol, there were no significant age differences in 30-day abstinence.

 

  • Conclusions

 

    • Results indicate that older adults have favorable long-term outcome following treatment relative to younger adults, but these differences may be accounted for by variables associated with age such as type of substance dependence, treatment retention, social networks and gender.
    • Age differences in these characteristics inform intervention strategies to support long-term recovery of older adults and provide direction for investigation of how age affects outcome.

Satre et al (2004)Five-year alcohol and drug treatment outcomes of older adults versus middle-aged and younger adults in a managed care program. Addiction. Oct;99(10):1286-97.

  • Under-diagnosis of problem drinking in older adults is particularly unfortunate because the risks associated with alcohol abuse and relapse for the elderly are significant.
  • Relapse, or the return to drinking following abstinence, may follow situations that are of particularly high risk for older adults.
    • These include situations related to anxiety, interpersonal conflict, depression, loneliness, loss or social isolation.
    • By helping patients to monitor these high-risk situations, to identify strategies that have been successful in promoting abstinence in the past, and to become engaged in treatment, relapse may be avoided and abstinence maintained.
  • Treatments such as cognitive-behavioural therapy, group and family therapies and self-help groups are just as effective for older adults as they are for other age groups. In fact, group and family therapies and self-help groups may be of particular benefit to older adults because of the emphasis on social support.
  • Medicinal adjuncts are also equally effective in the elderly, but strict compliance and careful monitoring of adverse effects are especially important in patients who take multiple medications. Because of their benign adverse effect profiles, naltrexone and acamprosate are particularly good pharmacological agents for relapse prevention in older adults.

Christopher Barrick, Gerard J. Connors Drugs & Aging August 2002, Volume 19, Issue 8, pp 583–594

Social care interventions

  • This study set out to qualitatively explore some of the strategies and approaches for working with alcohol problems in older people and how health and social care professionals may learn from them.
  • Given the high level of contact that older people have with social care professionals, they are ideally placed to identify and intervene with alcohol misuse in this population.
  • What these findings show is that relationship building, empathy and skilled communication are at the core of interventions with older drinkers and that the attendant risks to their health and wellbeing—both from themselves or others—need to be central to any intervention.
  • Studies from around the world have shown that alcohol problems in older people frequently go undetected or ignored. Given the ageing population globally and the evidence of increasing harm from alcohol consumption, this lack of detection must be addressed.
  • Social work education needs to play its role in supporting front line professionals to identify, intervene and safeguard older people from the potential damage from alcohol-related harm.

Sarah Wadd &amp; Sarah Galvani (2014) Working with Older People with Alcohol Problems: Insight from Specialist Substance Misuse Professionals and their Service Users, Social Work Education, 33:5, 656-669,

Inquiry into alcohol and substance misuse in Wales- 2016

Age Cymru’s final comment is very apt:

“Triggers such as bereavement, retirement or divorce can often lead older people to a greater feeling of loneliness or isolation. A number of the services that may have helped to tackle this root cause, such as day centres or Meals on Wheels, have been suffering from cut backs as a consequence of funding pressures, a situation further aggravated by the loss of public transport routes that are vital to older people, especially in rural areas. For substance misuse support and treatment for older people to be most effective, it is essential that the issue is approached holistically, recognising the impact that cuts on what appear to be unrelated services may be having upon the well-being of older people.”

Curriculum Mapping:

This episode covers the following areas (n.b not all areas are covered in detail in this single episode):

Curriculum Area
NHS Knowledge Skills Framework Suitable to support staff at the following levels:

  • Communication – Level 2-3
  • Personal development – Level 2-3
  • Quality – Level 1-2
Foundation curriculum (2016) Section

16

Title

Demonstrates understanding of the principles of health promotion and illness prevention

Core Medical Training Alcohol and Substance Dependence
Core Surgical Training Module 10 Health Promotion
GPVTS program 3.14 Care of People who Misuse Drugs and Alcohol
ANP (Draws from KSF) n/a
Higher specialist training – Geriatric medicine 19. Legal Framework for Practice (small section on substance abuse)
PA matrix of conditions Mental Health: Drug abuse/dependence

 

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