Substance Misuse in Older People

Masterclass in Old Age Psychiatry

Dr Tony Rao and Professor Ilana Crome

AIM To improve knowledge, skills and attitudes in the assessment, diagnosis,

treatment and care of older people with substance misuse (SM)

OBJECTIVES To be aware of age sensitive approaches to SM in older people To be able to conduct a thorough systematic assessment of SM To understand the limitations of current diagnostic criteria To identify physical and psychiatric co-morbidity To know the distinctive factors that are particular to older people’s SM To improve knowledge of age-specific screening , psychological

interventions and other treatment options for SM in older people To be aware of pharmacological changes and drug interactions in SM To improve knowledge of illicit drug use in older people

1986

2011

The Baby Boomers Turn 65

PEOPLE AGED 65 AND OVER PROJECTED POPULATION OF ENGLAND 2001-2031

7.8

16

8.6

17

10.2

19

12

22

0

5

10

15

20

25

Population of England (million) % of Total

2001201120212031

0 5000 10000 15000 20000

Illicit drugs

Physical inactivity

Fruit and vegetable intake

High Body Mass Index

Cholesterol

Alcohol

Tobacco

Blood pressure

EUROPEAN DISEASE BURDEN ATTRIBUTABLE TO SELECTED LEADING RISK FACTORS (2000)

Number of Disability-Adjusted Life Years (000s)

GLOBAL BURDEN OF DISEASE ATTRIBUTABLE TO 20 LEADING RISK FACTORS (2010)

Substance Misuse

Cannabis case grandmother is spared prison

MYTHS ABOUT ADDICTION AND OLDER PEOPLE

• At your age what does it matter?

• It is just a phase - you ‘ll grow out of it

• It’s your age – there is nothing you can do about it

• Illicit drug use: a young man’s disease

• Drug use and the older person – a contradiction in terms?

Non-judgemental approach,

Presentations can be atypical

Underreporting may occur

Additional information from other sources invaluable

Assessment weighted towards co-morbidity, functional abilities,

influence of loss , cognitive state (including influence of

substances and physical disorders) and social support

Multiple assessments often required to build up clinical picture,

including the need for vigilance around safeguarding

GENERAL PRINCIPLES OF ASSESSMENT

A Systematic Approach to Assessment

Demographics Age/Sex/ethnicity/living arrangements/living environment Presenting problem may be masked Discuss substances separately (Alcohol/nicotine/OTC/prescribed/Illicit) - Age at first use, weekend, weekly and daily use - Age of dependence syndrome - Maximum use and when/how long - Pattern of use over day/week - Route - Cost/’funding’ - Abstinence/relapse and link to stability/life events - Preferred substance Treatment (dates, service, intervention, outcome) Past and Family Psychiatric history Occupational and Psychosexual history Medical history (especially known complications form substance and effects on existing age-related impairment) Forensic history (especially public order and acquisitive offences)

ASSESSMENT-1

CASE PRESENTATION (courtesy of Dr Andrew Teodorczuk)

(Part 1) • AS 75 year old white British lady, living alone since

bereavement 4 years previously

• Moved into daughter’s home following fire in flat (put metal

dish into microwave) whilst intoxicated and suffered an alcohol-related seizure 2 days later

• Daughter knew nothing about mother’s drinking and passed off morning shakiness as anxiety

TYPICAL PRESENTATIONS ARE USUALLY ATYPICAL • Sleep complaints

• Cognitive impairment, memory or concentration disturbance

• Liver-function abnormalities

• Incontinence

• Poor hygiene and self-neglect

• Unusual restlessness/agitation or persistent tiredness

• Unexplained nausea and vomiting

• Changes in eating habits

• Slurred speech, tremor, poor coordination

• Frequent falls and unexplained bruising

• Masking by other mental and physical disorders

AGEISM ‘It’s all he/she has in life’

UNDER-REPORTING Viewed as stigmatising

BARRIERS TO IDENTIFICATION AND TREATMENT

MIS-ATTRIBUTION Misidentifying as physical illness/ depression /cognitive impairment

STEREOTYPING Poorer detection of drinking in: Women Higher levels of education Higher social class Widows

SPECIAL CONSIDERATIONS FOR OLDER ADULTS INCREASING INTAKE Cognitive impairment may interfere with self- monitoring

ATTEMPTS TO CUT DOWN There may be reduced incentive to decrease harmful use, which includes fewer social pressures and also fewer personal and family pressures secondary to ageism TIME SPENT USING/RECOVERING Negative effects may occur at relatively low levels of use CRAVING Older people may not recognise the urges as cravings, or may attribute it to something else such as anxiety, depression or boredom ROLE OBLIGATION The roles and expectations of older people and their families might have changed so that failure to fill expected role not acknowledged as a problem SOCIAL CONSEQUENCES Older people deny or may not realise that the problems with continuing use are associated with substance use REDUCED ACTIVITIES Older people may have decreased activities due to physical and psychiatric comorbidities or ‘slowing down’ Social isolation and disabilities also may detection more difficult

PHYSICAL HAZARDS Older people may deny or not realise that a situation that was once safe, has become physically hazardous ALCOHOL RELATED HARM Older people may deny or not realise that symptoms are substance related and practitioners may not attribute some or all problems as substance related TOLERANCE Older people may not develop dependence

WITHDRAWAL Even low intake may cause problems

CASE PRESENTATION (Part 2) MEDICAL ADMISSION • On medical ward, using non-judgemental approach,

admitted to drinking 1 bottle of spirits per day, starting in the morning and continuing throughout the day. Started around time of husband’s death and had escalated into dependence

• Referred to Drug and Alcohol team for systematic assessment. Considered for acamprosate but renal impairment was contra-indication to use

LIAISON PSYCHIATRY INVOLVEMENT • Assessed as having moderate depression but no other dual

diagnosis-citalopram started. Referred for bereavement counselling, day centre and care package set up to assist with shopping, provide meals on wheels and help with cleaning and laundry

CO-MORBID PSYCHIATRIC DISORDERS (DUAL DIAGNOSIS)

• Most common comorbid disorders are depression and alcohol related brain damage (ARBD); latter includes alcohol related dementia

• Dual diagnosis ranges from 21%to 66% • Older adults with depression are three to four times more likely

to have alcohol-related problems than those without (higher risk of suicide and social/functional impairment)

• In the under 65 population, ‘baby boomers’ born between 1946 and 1964 have higher suicide rates at any given age than earlier or later cohorts. Upper end of this cohort is now over 65 and a rapid growth in this over 65 population over next few decades

CO-MORBID PHYSICAL DISORDERS • Acute hazards from i-v use associated with venous damage,

infection and overdose. Other complications are bacterial endocarditis and Hepatitis C

• Other systemic effects include liver and pancreatic damage

from alcohol misuse; COPD and lung cancer from tobacco smoke; chronic nasal inflammation from crack cocaine; low blood sugar from cocaine and alcohol; cardiac disease from alcohol and cocaine misuse

• Increased risk of stroke from cannabis, cocaine,

amphetamines, phencyclidine (PCP) and Lysergic acid diethylamide (LSD)

• Increased risk of falls among older people with SM and should

always be considered in differential diagnosis

Social vulnerability Risk of falls, social/cultural isolation, financial abuse Social function Activities of daily living, statutory/voluntary/private input Social support Informal carers and friends, Social pressures Debt, substance using ‘carers’, open drug dealing Collateral information

Relatives GP consultations

Hospital discharge summaries Home carers Day centres

Housing officers/Wardens of Sheltered accommodation Criminal justice agencies

Consent and Capacity Investigations (including cognitive testing and neuroimaging)

ASSESSMENT-2

CASE PRESENTATION (Part 3) CMHT FOLLOW-UP • Family and GP became more closely involved

• Offered cognitive behavioural therapy and invited to attend

Alcoholic Anonymous meetings but attended day centre • Mood improved, care package stopped and discharged from CMHT

after 12 months, continuing day centre attendance and abstinent RELAPSE • Remained abstinent for 6 months until daughter moved to Dubai

• Stopped attending day centre; started drinking increasing amounts

and developed dependence over next 2 months, with poor self -care, weight loss and social isolation

MEDICAL RE-INVOLVEMENT • Admitted to hospital under S136 and found to have delirium

tremens

• Treated with intravenous thiamine, vitamin supplements and diazepam for alcohol withdrawal and transferred to a psychiatric unit

IN-PATIENT OLDER ADULT WARD INVOLVEMENT • No evidence of depression but history suggestive of cognitive and

functional decline

• Scored 63 out of 100 on ACE-R (Addenbrookes Cognitive Examination) and Neuroimaging showed generalised atrophic changes, enlarged ventricles and without any lobar predilection

• Diagnosed with alcohol related dementia

ACUTE PRESENTATIONS OF SUBSTANCE MISUSE • Acute alcohol intoxication may mask Wernicke's

encephalopathy and subsequent Korsakoff’s psychosis; it can also lead to delirium tremens

• Acute psychotic episodes occur with acute intoxication from

variety of substances (cannabinoids, stimulants and hallucinogens)

• Withdrawal states from alcohol/sedatives/hypnotics are also commonly associated with transient psychotic symptoms

• Other substances (nicotine, opiates, stimulants and cannabis)

have distinct withdrawal symptoms

PRESENTATIONS OF SUBSTANCE MISUSE IN OLDER PEOPLE Physical presentations • Seizures • Malnutrition and muscle wasting • Liver function abnormalities • Chronic pain or other unexplained somatic symptoms • Incontinence, urinary retention, difficulty urinating • Poor hygiene and self-neglect • Dry mouth or dehydration • Unexplained nausea and vomiting • Motor incoordination and shuffling gait • Frequent falls and unexplained bruising and head injuries

Psychiatric presentations • Sleep disturbances • Cognitive impairment with memory problems • Persistent irritability or anxiety • Change in mood with depression • Labile affect • Unusual restlessness and agitation • Unusual fatigue • Daytime sedation • Changes in eating habits • Difficulty in concentration • Difficulty in orientation

DISTINCTIVE ASPECTS OF OLDER PEOPLE WITH SUBSTANCE MISUSE

1. MENTAL CAPACITY • Often conflict between capacity and the role of practitioner in

addressing Substance Misuse

• Assessing mental capacity helpful in distinguishing an unwise decision from lack of capacity-centres around awareness of harm

• Mental capacity in SM can vary over time and affected by intoxication, withdrawal, mood state and cognitive state

2. ELDER ABUSE

• Substance misuse abuse is more likely to occur in perpetrators of abuse compared with the person suffering abuse

• Older women with neurological or mental disorder who misuse drugs or alcohol, are at highest risk of experiencing elder abuse

3. PROVISION OF CULTURALLY APPROPRIATE SERVICES • Major challenges in older BME populations accessing substance misuse services (e.g. languages barriers) • Higher rates of alcohol misuse the general population (e.g.) older

Irish and south Asian (Sikh) male migrants to the UK

• BME groups not homogenous-influenced by traditional beliefs, lifestyle choices, gender roles, assimilation and religious beliefs

CARE PLANNING • Found to lack mental capacity over decisions affecting living

arrangement and healthcare • Best interest meeting set up involving daughter; old age

psychiatrist; community psychiatric nurse; inpatient nursing staff, occupational therapist, social worker and Independent Mental Capacity Advisor

• DOLS (Deprivation of Liberty Safeguard) assessment completed. • Lack of mental capacity and potential risks at home meant that

needs best met in EMI (Elderly Mental Illness) nursing care • Followed up by older adult CMHT at EMI Nursing Home • Developed BPSD, with prominent impulsivity and aggression,

especially with care interventions • Started on risperidone 0.5mg after ECG showed no prolongation

of QTc interval • Less agitated and now more cooperative with care

MASTERCALSS SCREENING,

TREATMENT AND POLICY

PROFESSOR ILANA CROME Old age Faculty Residential Meeting

Glasgow March 2015

OUTLINE

• INTRODUCTORY BACKGROUND • CASE VIGNETTE • SCREENING TOOLS AND IDENTIFICATION • EARLY INVOLVEMENT WITH SERVICES AND BRIEF

INTERVENTION • RELAPSE AND PSYCHOSOCIAL AGE SENSITIVE

APPROACHES • COMBINED DISORDERS AND PARTNERSHIPS WITH

PROFESSIONALS, AGENCIES, CARERS • TREATMENT OUTCOMES AND POLICY

Old is not necessarily frail

• No such thing as a safe limit • Adult safe limits may not apply • For some healthy older people, 1 US (14 gm alcohol)

drink a day, and no more than 7 a week (UK unit = 8 gm)

• More than 3 US drinks a day is harmful • Should not drink and drive, swim, use machinery.

Should eat before drinking • Drink more slowly ie over two hours • For those with comorbid conditions, on medications,

no alcohol may be appropriate • Under review by the Chief Medical Officer

‘Safe’ limits

SUMMARY TABLE OF LIFE EXPECTANCY IN MALES (Chang et al 2011; Hayes et al 2011) • DIAGNOSIS DIFFERENCE FROM MALE UK POPULATION • Any serious mental illness -12.9 years (Chang et al 2011)

• Schizophrenia -14.6 years (Chang et al 2011) • Schizoaffective disorder -8.0 years (Chang et al 2011) • Bipolar affective disorder -10.1 years (Chang et al 2011)

• Substance use disorders -13.6 years (Chang et al 2011)

• Opioid use disorder -9.0 years (Hayes et al 2011) • Alcohol use disorder -17.1 years (Hayes et al 2011)

• Depressive episode &recurrent depressive disorder -10.6 years (Chang et al 2011)

CASE VIGNETTE 2 - SLIDE 1 Dr Andrew Teodorczuk • BACKGROUND: • JB – 63 man, self referral to D&A services for

polysubstance misuse. • Extensive previous history for addiction, started heroin

in 30s and developed dependence. • Started using with girlfriend, smoking 3-4 bags heroin a

day, injected after 6 months. • Contracted Hepatitis C and treated successfully. • Drinking socially over week ends in 20s; by 30s drinking

up to a bottle of vodka each night. • Cannabis smoking 2-3 times a week

SCREENING

Phase 1 – Ask

• About Alcohol, drugs, nicotine, other substance misuse

• Differentiate between harmful use and dependence

• Consider using age-appropriate screening instruments

• Be aware of and sensitive to ambivalence • Be non-judgemental and non-confrontational

Which substances? ALL!

• Nicotine • Alcohol and sedative/hypnotics • Stimulants, volatile substances & hallucinogens • Cannabis • Opiates • Prescribed • Over the counter • Using prescribed medications non-compliantly • Shared, borrowed, bought and sold!

SCREENING TOOLS AID IDENTIFICATION Time Training Treatment ‘Traditional Rating Scales’ lack sensitivity and validity, particularly

in the elderly • MAST, SMAST, GMAST, G-SMAST • CAGE • AUDIT – alcohol use disorder test • ARPS – alcohol related problems: for older age • DAPA-PC: for older age

Instruments

• G-MAST - Geriatric version of MAST >5 positive {MAST, SMAST, B-MAST (Michigan Alcohol Screening Test)}

• SMAST-G shorter version of the G-MAST

• CAGE - 4 questions >2 positive (Hinkin 2002)

• Alcohol related problems survey for older people (ARPS) and Short ARPS (shARPS)

• AUDIT (Alcohol use disorders test) or AUDIT -5 (Philpot et al 2003)

• MAST-G and CAGE most appropriate Beullens et al 2004)

• NO VALIDATED INSTRUMENTS FOR DRUG MISUSE – DAST

• Lack sensitivity and validity

Smoking, Cognition, Depression

• Brown bag review – prescription medication – over the counter, prescription, herbs, vitamins, topical ointments, dietary supplements

• Fagerstrom test for nicotine addiction: 6 questions with total of 10 indicating severe nicotine dependence

• Mini mental state – 30 item scale – attention, concentration, executive function, orientation, language

• Depression – Hamilton rating scale, Beck depression

QUESTIONNAIRE ASSESSMENT of NICOTINE DEPENDENCE

Fagerstrom Test for Nicotine Dependence (>6): 1. How soon after you wake up do you smoke your first

cigarette? <5 mins (3) 6-30 mins (2) 30-60 mins (1) >60 mins (0) 2. How many cigarettes do you smoke each day? <10 (0) 11-20 (1) 21-30 (2) >31 (3)

Short Michigan Screening Test – Geriatric Version – SMAST-G • 1 When talking with others do you underestimate

how much you drink? • 2 After a few drinks, have you sometimes not eaten

or been able to skip a meal because you do not feel hungry

• 3 Does having a few drinks help decrease your shakiness or tremors?

• 4 Does alcohol sometimes make it hard for you to remember parts of the day or night?

• 5 Do you usually take a drink to relax or calm your nerves?

• 6 Do you drink to take you mind off your problems? • 7 Have you ever increased your drinking after

experiencing a loss in your life? • 8 Has doctor or nurse ever said they were worried

or concerned about your drinking?

• 9 Have you ever made rules to manage your drinking?

• 10 When you feel lonely does having a drink help?

• Scoring: 2 or more YES responses is indicative of an alcohol problem

INSTRUMENTS

• Characteristics of measurement level: ‘readability’ or interview, clarity of questions, recall period, sensitivity or undesirability, ‘gold standard’

• Respondent characteristics: intoxication, drugs, personality, psychiatric illness, IQ, motivation

• Interviewer characteristics: in recovery, training, empathy, clinical or research

• Conditions of assessment: confidentiality, setting, parents, consequences of assessment, use of other sources

• Cultural aspects

Advantages Disadvantages • Standardised recording • Shared understanding • Assists information sharing • Tried and tested • Checklist of issues • Allow measurement • ‘Cross-check’ • Self completion allow

participation

• Subjectivity in scoring • Lengthy and complex • Training needs – ongoing • Cost • Wording • Not appropriate • Adaptation? • Package of tools?

Advantages Disadvantages • Helps to get person ‘talking’ • Evidence on outcomes • Quick visual tool of where

they are at • Assist care planning • 2 or 3 together • Adapted for local use

• Alcohol – fewer tools • Lack of flexibility • Loss of individuality for the key

worker • Formality of tools • Tick boxes prevent self

expression

• Reading and writing skills? • Focus on tools for statistics

What to consider when choosing a tool

• Primary use • Validation • What aspects of the older person • Approach suitable? • How long does it take to complete? • Staff training • Cost • IT limitations

Dan Blazer Psychiatry Online 2012 American Psychiatric Association • ‘The first step in addressing this invisible yet

emerging epidemic is proper screening and an estimate of risk given other factors. All older adults should be screened, but some subgroups are at greater risk. Being male, Native American, or Alaska native; being unmarried; and having a lower income and less education, a diagnosis of other psychiatric disorders, and a history of problems with the law and incarceration increase the risk among older adults for experiencing substance use problems.

DAPA-PC Drug and Alcohol Problem Assessment for Primary Care (Blazer)

• A computerized screening system quickly identifies substance abuse and related problems in primary care settings

• Can be used by psychiatrists as well • DAPA-PC is a self administered, Internet-based

screening instrument • Automatic scoring • Generation of a patient profile for medical reference, • Presentation of unique motivational messages and

advice for the patient.

Information technology

• Save clinicians’ time • Patients to be screened while in the waiting room, • Clinician to follow-up with a patient only when

prompted by the results of the screening. • Computerized screening may lend itself more to an

honest revelation regarding drug use compared with face-to-face discussions.

• Acceptability of computers by the elderly will only increase.’

‘FRAMES’ (Miller & Sanchez 1994)

• Feedback which is personalised • Responsibility for change • Advice on how to change • Menu of options for change • Empathy: caring, understanding, warmth • Self efficacy: hope that change is within reach • But, not evaluated in older people

Part of the process

• Continuous ie not one off • Non-threatening, non-judgmental so that person

remains engaged & positive dialogue • User choice and participation • Impact of SM on older person • Prioritisation of risks • Problems, strengths, goals and care plans • Skilled professional support

CASE VIGNETTE 2 Slide 2 – early involvement with services • Pattern lasted for 5 years • Car accident precipitated inpatient admission • Alcohol and opioid detoxification • Investigations revealed fatty liver so advised to

reduce alcohol • He married, had a child, opened a gym. • Apart from cigarettes he stopped alcohol,

recreational drugs for 25 years

Phase 2 – Assess • Degree of dependence – REQUIRED DETOXIFICATION

• Knowledge of substance misuse effects – HAD EFFECT EG

CAR ACCIDENT

• Level of motivation or “stage of change” – STOPPED

HIMSELF

• Goals (e.g. abstinence versus harm reduction) -

ABSTINENT

• Treatment choices – BRIEF INTERVENTION

• Clinical manifestations of substance misuse – LIVER

• Other considerations related to age group

Phase 3 – Advise •Use brief “motivational interviewing” framework

•Provide space to express concerns

•Offer personalised feedback about clinical findings and investigations – LIVER FUNCTION TESTS

•Offer brief advice

•Provide self-help materials, e.g. manuals

CASE VIGNETTE 2 Slide 3 – relapse • Developed COPD and hypertension • Sold business due to failing health aged 60 • Hospital admission due to septicaemia • Prescribed morphine for pain which continued after discharge

home • When prescription was stopped he started using heroin again • He was using 3 bags of heroin but was abstinent of alcohol • His wife advised seeking treatment and he commenced

methadone • He progressed well with intensive treatment from recovery team: • Psychological treatments, mutual aid groups and relapse

prevention medication ie CBT, NA, regular urine testing

Phase 4 – Assist •Instil hope – HAD STOPPED PREVIOUSLY •Acknowledge loss of confidence and self-esteem •Individually tailored goals (e.g. abstinence requires “quit date” to plan for safe termination of use) - METHADONE •Work through coping strategies, including managing cue avoidance – CBT, NA

•HAD MEDICAL PROBLEMS LIKELY RELATED TO SMOKING AND ALCOHOL

CASE VIGNETTE 2 – Slide 4 – depression • His son was diagnosed with terminal cancer • He became depressed, lost weight, reduced eating and

drinking, poor sleep • Lost interest in activities: football, socialising • Voiced ideas about life not being worth living • Deterioration in mental and physical health noted by

carers/workers • Continued to be abstinent of street drugs and alcohol • Admission arranged for further assessment and

treatment

Inter-relationships • A primary psychiatric illness precipitating

or leading to substance misuse • Dysphoria or distress ie ‘minor’ symptoms

leading to substance use • Substance misuse worsening or altering

the course of a psychiatric illness • Substance use, intoxication, harmful use,

dependence leading to psychological symptoms or syndromes

• Substance withdrawal leading to psychological symptoms or illnesses

CASE VIGNETTE 2 – SLIDE 5 – assessment and treatment

• ON ADMISSION: Very depressed with suicidal ideation • Underwent physical examination and investigations:

drug screen was negative except for methadone; negative breath alcohol;

• Treatment – 15 minutes observation • Commenced on sertraline which gradually increased • Initial review: collateral information about events

leading to admission • Wife visited regularly; MDT meetings with family;

Physiotherapy and occupational therapy • Discharged after improvement in mental state with

OPA, CPN, drug and alcohol worker

Phase 5 – Arrange • Admission to a specialist or appropriate unit in likelihood of: REGULAR OBSERVATIONS, ANTIDEPRESSANT MEDICATION, PHYSIOTHERAPY AND OCCUPATIONAL THERAPY, FOLLOW UP FROM CPN AND DRUG WORKER - Severe withdrawal, including delirium tremens - Unstable social circumstances - Severely dependent, frequent relapse - Severe co-morbid physical illness - Co-morbid mental illness, including suicidal ideation – DEPRESSION AND SUICIDAL IDEATION - Polysubstance misuse

Phase 1 – Ask

• About Alcohol, drugs, nicotine, other substance misuse

• Differentiate between harmful use and dependence

• Consider using age-appropriate screening instruments

• Be aware of and sensitive to ambivalence • Be non-judgemental and non-confrontational

Phase 2 – Assess

• Degree of dependence • Knowledge of substance misuse effects • Level of motivation or “stage of change” • Goals (e.g. abstinence versus harm reduction) • Treatment choices • Clinical manifestations of substance misuse • Other considerations related to age group

Phase 3 – Advise •Use brief “motivational interviewing” framework

•Provide space to express concerns

•Offer personalised feedback about clinical findings and investigations

•Offer brief advice

•Provide self-help materials, e.g. manuals

Phase 4 – Assist •Instil hope •Acknowledge loss of confidence and self-esteem •Individually tailored goals (e.g. abstinence requires “quit date” to plan for safe termination of use) •Work through coping strategies, including managing cue avoidance

Phase 5 – Arrange

• Admission to a specialist or appropriate unit in likelihood of: - Severe withdrawal, including delirium tremens - Unstable social circumstances - Severely dependent - Severe co-morbid physical illness - Co-morbid mental illness, including suicidal ideation - Polysubstance misuse - History of frequent relapse

TREATMENT AND POLICY

Alcohol dependence was last among 30 medical conditions in proportion of care received as evidence would recommend

Senile cataract 78.7% Breast cancer 75.7% Prenatal care 73.0% Hypertension 64.7% Asthma 53.5% Diabetes Mellitus 45.4% Urinary Tract Infection 40.7% Atrial Fibrillation 24.7% Alcohol Dependence 10.5%

Source: McGlynn E., et al., (2003). The quality of health care delivered to adults in In the United States. New England Journal of Medicine, 348.

Critical issues in treatment

What is an appropriate treatment goal? What is motivation for psychological

change? Regularity and credibility of medical

advice? How appropriate are techniques for

assessment, advice, assistance? IT, telephone, larger print Ask Assess Advise Assist Prescribe

Arrange! What happens post-treatment?

PHARMACOLOGICAL TREATMENT

Trials and guidelines

Usually dictated by clinical trials

Complex patients excluded ie unrepresentative samples eg older, substance users, comorbidity

Combined treatments rarely studied

Guidelines are not for older people

Pharmacological treatment Medication Licensed Age limits Specific older Diazepam Alcohol withdrawal Not in children <half adult dose

In anxiety Chlordiaze-poxide Alcohol

withdrawal Not in children < half adult dose for

anxiety

Disulfiram Alcohol deterrent Not in children None

Methadone Opiate addiction Not in children Caution

Subutex Opiate addiction >16 years None

Lofexidine Opiate detox’n Not in children Caution

Nicotine Replacement NRT

Nicotine withdrawal > 18 years None

Bupropion Smoking cessation > 18 years Caution

Pharmacological treatments

• Need to diagnose dependence • ON EACH DRUG SEPARATELY • Management of withdrawal symptoms eg

benzodiazepines, carbemazepine; methadone, clonidine, lofexidine buprenorphine;nicotine replacement, bupropion

• Maintenance of abstinence eg methadone, buprenorphine;nicotine replacement, bupropion

Pharmacological treatments

• Prevention of complications eg vitamin supplementation: Wernicke Korsakoff’s syndrome Thiamine

• Relapse prevention 1. Block pleasant effects: naltrexone 2. Reduce craving: acamprosate 3. Unpleasant reaction with alcohol:

disulfiram • Psychiatric conditions eg depression • Physical conditions eg diabetes

Pharmacological treatment options • Drugs not investigated/licensed for over 65s • Benzodiazepines – caution due to accumulation but

need to give enough to cope with withdrawal • Acamprosate, disulfiram and naltrexone with

utmost caution WITH SPECIALIST SUPPORT • Methadone and buprenorphine supervised • Nicotine replacement and bupropion if not

contraindicated

Alcohol • Benzodiazepines

• Disulfiram

• Acamprosate

• GABA (gamma-aminobutyric acid) receptors

• Blocks accumulation of acetaldehyde by blocking action of alcohol dehydrogenase

• GABA analogue

Opiates • Methadone

• Burprenorphine

• Naltrexone

• Opiate agonist

• Partial opioid agonist and antagonist

• Opioid antagonist

Nicotine

• Nicotine replacement

• Bupropion

• Varenicline

• Nicotine agonist

• Acts on NA and DA transmission

• Selective nicotine receptor partial agonist

PSYCHOSOCIAL AGE SENSITIVE

TREATMENT

Psychosocial treatment

• Formal interventions aimed at reduction in substance use and problems including meetings with client and health care provider

• Formally trained to address psychological psychiatric or substance related issues

• Entered into treatment in mental health or non mental health in/out patient or residential settings

• Alliance based on respect, support, positive in motivated, trained, experienced staff

• Flexible in goals, approach, location, mode, duration, unpredictability in needs and function eg phones, care homes, postponement until safe housing, food, after detoxification

AGE SENSITIVE TREATMENT

No single empirically supported psychosocial treatment approach as superior Responsive to needs and supporting adaptive coping strategies

BRIEF INTERVENTIONS

What is a brief intervention?

• Simple brief intervention – structured advice taking no more than a few minutes

• Extended brief intervention – structured therapies taking perhaps 20-30 minutes, one or more repeat sessions

BRIEF INTERVENTIONS

• Are NOT effective for dependent drinkers • Effective in hazardous/harmful drinkers to low risk

levels in primary care, A&E, psychiatric patients, needle exchange schemes, somatic illness

• Persist, need boosters, reduce mortality • Effective in reducing alcohol related problems eg in

A&E in young men • Inconclusive evidence for drinkers in general

hospital where MI may be better

Differences with between Treatment Approaches

Confrontation of Denial Approach Motivational Interviewing Approach

Heavy emphasis on acceptance of self as ‘alcoholic’; acceptance of label seen as essential for change

De-emphasis on labels; acceptance of ‘alcoholism’ label seen as unnecessary for change to occur

Emphasis on disease of alcoholism which reduces personal choice and control

Emphasis on personal choice regarding the future use of alcohol and other drugs

Therapist presents perceived evidence of alcoholism in an attempt to convince the client of the diagnosis

Therapist conducts objective evaluation but focuses on eliciting client concerns

Resistance seen as denial, a trait characteristic of problem drinkers and requiring confrontation

Resistance is met with reflection

Non directive vs Motivational Enhancement

Non-Directive Approach Motivational Enhancement Approach Allows the client to determine the content and direction of counselling

Systematically directs the client toward motivation for change

Avoids injecting the counsellor’s own advice and feedback

Offers information and feedback where appropriate

Empathic reflection is used non-contingently Empathic reflection is used selectively to reinforce certain points

Explores the client’s conflicts and emotions as they are currently

Seeks to create and amplify the client’s discrepancy in order to enhance motivation for change

Cognitive behavioural vs Motivational

Cognitive Behavioural Approach Motivational Enhancement Approach Assumes that the client is motivated to change; no direct strategies for building motivation for change

Employs specific principles and strategies for building client motivation

Seeks to identify and modify maladaptive conditions

Explores and reflects client perceptions without labelling or ‘correcting’ them

Prescribes specific coping strategies Elicits possible change strategies from the client

Teaches coping behaviours through instruction, modelling, directed practice and feedback

Responsibility for change methods is left to the client; avoids training, modelling and practice

Teaches problem-solving strategies

Motivational interviewing/enhancement

• Non-confrontational principles and style

• Increase effectiveness of more extensive psychosocial treatments

• Could be effective as preparation for more intensive treatments

• Potentially more cost effective

Motivational enhancement

• Effective standalone for moderate alcohol dependence

• First step for severe dependence

• For users with high level of anger

• Training an absolute must

Implications

• General style of treatment

• Well suited for firstline treatment within stepped care

• Require considerable skill and training and supervision are important

Some interlinked concepts

• Ageing

• Multiple pathology

• Vulnerability and resilience

• Models of care

TREATMENTS AND OUTCOMES

Overview of Study Findings - Alcohol

Similar treatment considerations appeared to apply for older people as applied generally, so older age should not be a barrier to addressing drinking problems11.

Potential for good outcomes in those older people

who seek treatment; possible they may have achieved even better outcomes in an elder-specific program12.

Overall recovery prospects of older patients found

to be encouraging13. Long term management requires more research

Overview of Study Findings - Alcohol

Number of patients who achieve their follow-up goal is at least comparable to that of other populations6.

Physicians can help older adults who drink excessively7. Those patients in elder-specific treatment appear to improve

across a wide variety of outcome domains8. Older adults who seek treatment have the capacity to change

and do well compared with younger adults, and can be treated effectively outside of an age specific program9.

Brief Advice and Motivational Enhancement are equally

successful for both older and adult populations10.

Overview of Study Findings – Smoking, Heroin, Prescription Medications

Smoking:

Nurse practitioner intervention led to decreased smoking

Older smokers benefit as much as younger smokers from brief office-based counselling

Women found simple smoking cessation interventions in primary care helpful; light smokers were more likely to stop than heavy smokers

Heroin:

Older patients might have fewer problems, do very well

Prescription Drugs:

Participation led to a significant reduction in benzodiazepine, narcotic and overall prescription use; the reduction in health care utilisation observed may translate to savings in health care costs

SUMMARY: TREATMENT EFFECTIVENESS

• OLD AGE SHOULD NOT BE A BARRIER TO

TREATMENT • Prescription drug use, especially polypharmacy,

as well as OTM and other substances. • Enrolment of older patients in trials Eg

Naltrexone and disulfiram • Combined treatments: decision making,

mechanism of action and algorithms • Recommend any particular intervention, specific

programme, service model over long term? OLD AGE SHOULD NOT BE A BARRIER TO

TREATMENT

COST EFFECTIVENESS

Economic benefits – saving of £5 for every £1 invested

Social benefits also Healthcare costs may

increase in short term Alcohol interventions

are highly cost effective in comparison with other health care interventions

THE 5 A’s

• ASK – all drugs, dependence, ambivalence, non-judgemental

• ASSESS – motivation, goals, complications • ADVISE – ‘brief intervention’ – feedback,

information, self help material • ASSIST – coping strategies, hope, self esteem • ARRANGE – admission – severe addiction,

polysubstance, social, comorbidity, relapse

Approaches

• Brief intervention- FRAMES ie feedback, responsibility, advice, menu, empathy, self efficacy

• Motivational interviewing – reduces ambivalence, rolls with resistance

• Motivational enhancement – active goal orientated, manualised, accepts stage of change point

• Cognitive behavioural therapy – active goal focussed, problem solving – A B C

Age sensitive treatment

• Trained staff: Supportive and non-confrontational by trained staff who enjoy working with older people

• Changing and adaptive to needs: Backdrop of changing needs and limitations

• Other problems: accommodation, finance, physical problems

• Flexibility: goals, approach, location, mode and duration • Accessibility – homebound, rural, transport • Gender eg women later onset, rapid progression,

psychiatric comorbidity, more barriers to treatment, lower income, less insurance, care giving roles

• Cultural differences – in US 25% are from ethnic minorities

Age sensitive treatment

• Client functioning: • slower pace • speaking slowly and clearly, • shorter treatment sessions, • structured presentation though multiple methods,

repeating and reviewing, • summarizing, • written record • Holistic – resources and resilience • Problem solving and social skills

Adjuncts to age sensitive treatment • Psycho-education • Screening for infectious disease • Mutual self help - transportation, disability, reluctance to go

out in the evening, discomfort at being with younger people, or those who have used illicit drugs

• Once engaged, AA involvement predicts better outcomes in older people

Adjuncts to mixed age treatment

• Age segregated or mixed age treatment can benefit older people

• Preferences: Some older people may need and prefer to be separated due to limitations related to health problems

• Care coordination is key for effective and efficient treatment • Stepped care is recommended • Information technology: less intense, less stigmatising and

may be attractive

Components of age-sensitive treatment

• Assessment – biopsychosocial • Protocols, treatment plans and goals

with re-assessment • Comorbidity: pain, cognitive

dysfunction, depression, other substance use

• Protocols for referrals and care coordination – addiction and geriatric

• Empirically supported psychosocial and pharmacological interventions

• Treatment adjuncts

TREATMENT PARTNERSHIPS

SUMMARY

• No single empirically supported psychosocial treatment approach as superior

• Age sensitive: responsive to needs and supporting adaptive coping strategies

• Coordinated • Least intensive but use higher if needed • Age versus mixed age – no consensus

Age alone should never be seen as a bar to any form of treatment which should initially be active unless complete assessment can be made

Substance misuse trials older people

• Smoking Prevention among People aged 60 and over: A Randomised Controlled Trial. Vetter NJ, Ford D. 1990.

• Reaching Midlife and Older Smokers: Tailored Interventions for Routine Medical Care. Morgan GD, Noll EL, Oreleans T, Rimer BK, Amfoh K, Bonney G. 1996.

• Older adult treatment outcome following elder-specific inpatient alcoholism treatment. Blow FC, Walton MA, Chermack ST, Mudd SA, Brower KJ. 2000.

• Reducing substance dependence in elderly people: The Side Effects Program. Brymer C, Rusnell I. 2000.

• Alcoholism Treatment Adherence: Older Age Predicts Better Adherence and Drinking Outcomes. Oslin DW, Pettinati H, Volpicelli JR. Novemeber-December 2002.

Substance misuse RCTs older people

• Treatment outcomes of older patients with alcohol use disorders in community residential programs. Lemke S, Moos R. March 2003.

• Outcomes at 1 and 5 years for older patients with alcohol use disorders. Lemke S, Moos R. 2003.

• Comparison of Consumption Effects of Brief Interventions for Hazardous Drinking Elderly. Gordon AJ, Conigliario J, Maisto SA, McNeil M, Kraemer KL, Kelley ME. 2003.

• Contrasting outcomes of older versus middle-aged and younger adult chemical dependency patients in a managed care program. Satre DD, Mertens J, Arean PA, Weisner C. July 2003.

• Gender differences for treatment outcomes for alcohol dependence among older adults. Satre DD, Mertens JR and Weisner C. September 2004.