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Alcohol and substance abuse in older people 

Alcohol and substance abuse in older people
Chapter:
Alcohol and substance abuse in older people
Author(s):

Henry O’Connell

and Brian Lawlor

DOI:
10.1093/med/9780199644957.003.0049
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Alcohol use disorders (AUDs) are common in older people and are associated with considerable morbidity and mortality. However, clinical practice, medical research, public health initiatives, and media attention focus primarily on how such problems affect younger people, partly because of the more clinically ‘silent’ nature of AUDs in older people. As a result, AUDs are less likely to be detected in older people, because of a general lack of awareness and knowledge of older-specific aspects of clinical presentation and the use of inappropriate screening instruments and diagnostic criteria that are geared towards younger people. Furthermore, even when such problems are detected in older people, they are less likely than younger people to be treated adequately or referred on to specialist treatment facilities (Khan et al., 2002; O’Connell et al., 2003a; Dar, 2006).

The ageing of populations worldwide means that the absolute number of older people with AUDs is on the increase and, due to worldwide cultural changes in the past three to four decades, cohorts of people reaching old age in the coming years, e.g. the so-called baby boomers (Patterson and Jeste, 1999), are likely to have higher prevalence rates of AUDs and other substance use disorders than current and past generations of older people. Morbidity associated with AUDs in older people affects practically all aspects of the individual’s physical, psychiatric, cognitive, and social health and wellbeing, and makes a substantial contribution to premature mortality. Such morbidity and mortality also has significant knock-on effects for the individual’s family and carers, for healthcare professionals and service planners, and for society in general.

Therefore, it is imperative that increased attention at all levels be focused on this important area, with the aims of increasing detection rates and providing accessible, specialized and effective treatment services, thereby preventing the development of a ‘silent epidemic’ of alcohol and substance use disorders in older people (O’Connell et al., 2003a; Dar, 2006; Reid and Anderson, 1997).

Older people use more medications and are at a higher risk of inappropriate medication use (IMU), resulting in more adverse events than any other age group (Chutka et al., 2004, 2005; Barry et al., 2006; Gallagher et al., 2008) and also with the potential for development of abuse and dependence on psychoactive agents. Various factors combine to increase this risk, including high levels of prescribing of both psychotropic and nonpsychotropic medications for older people, which may at times be inappropriate, along with variable compliance, altered pharmacokinetics, reduced functional ability, and increased levels of physical, psychiatric, and cognitive morbidity. As with AUDs, clinical features of IMU may be atypical and masked by other conditions and thus go undetected and untreated (Beers et al., 2000).

Illicit drug use in older people is far less of a problem in comparison to AUDs and IMU and so will receive less attention in this chapter. However, there is emerging evidence that, as with AUDs, generations of people reaching old age in the coming decades may carry with them higher levels of illicit drug use than current and past generations of older people (Patterson and Jeste, 1999; Dowling et al., 2008). Principles similar to those seen with AUDs and IMU apply, in that lower levels of drug intake are required to cause harm and presentation may be atypical and thus go undetected.

This chapter covers the many older-specific aspects of alcohol and substance use disorders and is divided in two ways. First, apart from the Conclusion, there are seven main sections: Definitions and Diagnosis; Epidemiology; Aetiology, Risk Factors, and Associations; Clinical Features and Comorbidity; Clinical Assessment, Investigations, and Screening; Management and Prevention, and finally Prognosis. Second, each of these seven sections is further divided into three subsections, relating to AUDs, IMU, and the abuse of illicit substances. We have also discussed smoking in older people at the end of the chapter.

Definitions and Diagnosis

AUDs in older people

Alcohol use disorders is a general term used to include the wide spectrum of problems associated with alcohol use, from excessive consumption of alcohol above recommended ‘safe’ or ‘healthy’ levels of intake to harmful use and alcohol dependence. AUDs and problems associated with use of other substances forms section F1 of the ICD-10, ‘Mental and behavioural disorders due to psychoactive substance use’ (see Table 49.1). The general criteria for harmful use and dependence syndrome of all substances, including alcohol, are given in Tables 49.2–49.6. The ICD-10 (World Health Organization, 1992) and DSM-IV (American Psychiatric Association, 1994) use largely similar diagnostic criteria (see, for example, Tables 49.4 and 49.5) and we will refer mainly to ICD-10 criteria in this chapter.

Table 49.1 ICD-10: Mental and behavioural disorders due to psychoactive substance use

  1. F10. Mental and behavioural disorders due to use of alcohol

  1. F11. Mental and behavioural disorders due to use of opioids

  1. F12. Mental and behavioural disorders due to use of cannabinoids

  1. F13. Mental and behavioural disorders due to use of sedatives or hypnotics

  1. F14. Mental and behavioural disorders due to use of cocaine

  1. F15. Mental and behavioural disorders due to use of other stimulants, including caffeine

  1. F16. Mental and behavioural disorders due to use of hallucinogens

  1. F17. Mental and behavioural disorders due to use of tobacco

  1. F18. Mental and behavioural disorders due to use of volatile solvents

  1. F19. Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances

Table 49.2 ICD-10 criteria for acute intoxication

  1. G1. There must be clear evidence of recent use of a psychoactive substance (or substances) at sufficiently high dose levels to be consistent with intoxication.

  1. G2. There must be symptoms or signs of intoxication compatible with the known actions of the particular substance (or substances), as specified below, and of sufficient severity to produce disturbances in the level of consciousness, cognition, perception, affect, or behaviour that are of clinical importance.

  1. G3. Symptoms or signs present cannot be accounted for by a medical disorder unrelated to substance use and are not better accounted for by another mental or behavioural disorder.

Acute intoxication frequently occurs in persons who have more persistent alcohol or drug-related problems in addition. Where there are such problems, e.g. harmful use, dependence syndrome, or psychotic disorder, they should also be recorded.

Table 49.4 ICD-10 criteria for dependence syndrome

Three or more of the following manifestations should have occurred together for at least 1 month or, if persisting for periods of less than 1 month, should have occurred together repeatedly within a 12-month period:

  1. (1) a strong desire or sense of compulsion to take the substance;

  1. (2) impaired capacity to control substance taking behaviour in terms of its onset, termination, or levels of use, as evidenced by the substance being often taken in larger amounts or over a longer period than intended, or by a persistent desire or unsuccessful efforts to reduce or control substance use;

  1. (3) a physiological withdrawal state when substance use is reduced or ceased, as evidenced by the characteristic withdrawal syndrome for the substance, or by use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms;

  1. (4) evidence of tolerance to the effects of the substance, such that there is a need for significantly increased amounts of the substance to achieve intoxication or the desired effect, or a markedly diminished effect with continued use of the same amount of the substance;

  1. (5) preoccupation with substance use, as manifested by important alternative pleasures or interests being given up or reduced because of substance use; or a great deal of time being spent in activities necessary to obtain, take, or recover from the effects of the substance;

  1. (6) persistent substance use despite clear evidence of harmful consequences, as evidenced by continued use when the individual is actually aware, or may be expected to be aware, of the nature and extent of harm.

Table 49.5 DSM-IV criteria for dependence syndrome

As with ICD-10, three or more of the criteria listed below must have been met in the previous 12 months to constitute a diagnosis of substance dependence.

  1. 1. Tolerance, as defined by either of the following:

    1. (a) need for markedly increased amounts of substance to achieve intoxication or desired effect; or

    1. (b) markedly diminished effect with continued use of the same amount of the substance.

  1. 2. Withdrawal, as manifested by either of the following:

    1. (a) characteristic withdrawal syndrome for the substance; or

    1. (b) the same (or a closely related) substance is taken to relieve avoiding withdrawal symptoms.

  1. 3. The substance is often taken in larger amounts or over a longer period than was intended.

  1. 4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

  1. 5. A great deal of time is spent in activities necessary to obtain the substance (e.g. visiting multiple doctors or driving long distances), use the substance (e.g. chain smoking), or recover from its effects.

  1. 6. Important social, occupational, or recreational activities are given up or reduced because of substance use.

  1. 7. 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 (e.g. current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite a peptic ulcer made worse by alcohol consumption).

Most research and clinical descriptions of alcohol status describe individuals as belonging to one of five main alcohol categories: abstinent (for a specified period of time or for their entire lifetime); moderate drinkers, i.e. individuals who drink within recommended ‘safe’ or ‘healthy levels’ and who do not have criteria for heavy use or other AUD; individuals with ‘heavy use’ of alcohol (i.e. those who drink above recommended levels but without obvious negative social, behavioural, or health consequences); individuals with alcohol dependence syndrome (see Tables 49.4 and 49.5); and a fifth group whose alcohol use is problematic but milder in severity than dependence; these latter individuals may be described as being problem drinkers or having harmful use (ICD-10) or abuse (DSM-IV) of alcohol (see Table 49.3). ‘Binge drinkers’, i.e. individuals who do not fulfil criteria for alcohol dependence syndrome but who have a pattern of regular heavy drinking sessions associated with adverse health consequences, may also be included in the latter group.

Table 49.3 ICD-10 criteria for harmful use

  1. A. There must be clear evidence that the substance use was responsible for (or substantially contributed to) physical or psychological harm, including impaired judgement or dysfunctional behaviour.

  1. B. The nature of the harm should be clearly identifiable (and specified).

  1. C. The pattern of use has persisted for at least 1 month or has occurred repeatedly within a 12-month period.

  1. D. The disorder does not meet the criteria for any other mental or behavioural disorder related to the same drug in the same time period (except for acute intoxication).

ICD-10 states that identification of the psychoactive substance (alcohol or otherwise) should be based on as many sources as possible. These include self-report data, analysis of blood and other body fluids, characteristic physical and psychological symptoms, clinical signs and behaviour, and other evidence such as a drug being in the patient’s possession or reports from informed third parties.

An individual’s drinking status is not static and may vary throughout life, because of changes in life circumstances and health characteristics. For example, individuals with alcohol dependence syndrome in their younger years may quit alcohol use completely and be described as alcohol abstainers in their later years, but continue to have some of the adverse health characteristics of individuals with active alcohol dependence syndrome, such as residual physical or psychological health problems, social and occupational impairments acquired when their AUD was active, or inherent personality traits such as impulsivity, hyperactivity, or antisocial personality traits that put them at risk for other physical and mental health problems. The presence of these so-called sick-quitters among nondrinkers in observational studies may in part explain the less favourable health characteristics of alcohol abstainers in comparison to moderate drinkers. Furthermore, such individuals may be at risk of developing a relapse of their AUD in the context of health problems or changes in social circumstances in later life.

Definitions of a unit of alcohol are given in Table 49.7. The recommended upper limits of alcohol intake are 14 units per week for women and 21 units per week for men, according to the Royal Colleges Report (1995). These units should not all be consumed at the one sitting. However, these recommendations relate to the general population of all ages, and ‘safe’ or ‘healthy’ levels of intake are likely to be lower for older people. Within the broadly defined group of older people, spanning as it does four decades in age, even more detailed recommendations should apply. For example, a 90-year-old woman who has multiple medical problems is unlikely to tolerate the same amount of alcohol as a fit and healthy 65-year-old man.

Table 49.7 Definitions of a standard drink

A standard drink of beverage alcohol is equivalent to a 12-floz (US; 355 ml) domestic beer (alcohol content about 4%), a 5-fl oz (US; 148 ml) glass of table wine (about 12% alcohol), or a mixed drink containing 1–1.5 fl oz (US; 29–40 ml) hard liquor (about 40% alcohol).

The US National Institute of Alcohol Abuse and Addiction (NIAAA) recommends no more than one drink per day for older people (NIAAA, 1998), but there are no such older-specific criteria in Europe or described by the ICD-10 or DSM-IV. Therefore, in applying existing diagnostic criteria, AUDs in older people may be missed, as older people may not display the classical symptoms or signs of AUDs seen in younger people, such as a craving or compulsion, and signs of intoxication, changes in tolerance, withdrawal states, and other diagnostic criteria for AUDs may be atypical or masked by other health problems. Furthermore, older people may not experience the same degree of legal, family, and occupational problems associated with AUDs as seen in working-age adults, and biophysical screening measures for AUDs such as mean corpuscular volume (MCV) and abnormal liver function tests may not be as sensitive in older people. Older people with covert AUDs may present with a wide range of seemingly unrelated problems, such as unexplained falls and fractures, confusion, treatment-resistant depression, and adverse drug reactions, and the underlying AUD is likely to go undetected unless a high degree of clinical suspicion is maintained (this is discussed in more detail in the section Clinical Assessment, Investigations, and Screening; see also Table 49.10).

Table 49.10 Physical, neuropsychiatric, and sociodemographic aspects of AUDs in older people

Gastrointestinal

Hepatic problems: elevated liver enzymes; fatty liver; alcoholic hepatitis; cirrhosis; malignancy

Gastritis, peptic ulcer disease, and bleeding

Oesophageal varices

Acute and chronic pancreatitis

Malignancies

Mouth, pharynx, larynx, oesophagus, hepatic, colorectal, pancreatic

Cardiovascular

Ischaemic heart disease

Hypertension

Alcohol-induced arrhythmias

Congestive heart failure

Alcoholic cardiomyopathy

Haematological

Macrocytosis (acute effect of alcohol intake and due to vitamin B12 and folate deficiency in chronic AUD)

Anaemia (due to gastrointestinal problems)

Musculoskeletal

Falls and fractures

Reduced bone density

Myopathy

Metabolic

Hypoglycaemia

Hyperuricaemia

Elevated lipids

Diabetes more difficult to control

Neuropsychiatric

Cognitive impairment and dementia

Frontal lobe impairment

Wernicke–Korsakoff syndrome

Cerebellar cortical degeneration

Central pontine myelinosis

Marchiafava–Bignami disease

Depression

Psychosis

Intoxication

Withdrawal syndrome (may be more difficult to treat in older people)

Suicide

Other

Alcohol–drug interactions

Aspiration pneumonia

Road traffic and other accidents

Sociodemographic

Male gender

Divorced, widowed, and single status

Social isolation

Upper and lower ends of socioeconomic spectrum

A stereotypical idea of the ‘down and out’ alcoholic with a high consumption of alcohol is also likely to lead to missed diagnoses, as older people may experience significant health problems even at relatively low levels of intake, or experience new problems in later life due to age-related reductions in tolerance, even while continuing a lifelong pattern of moderate consumption.

Inappropriate medication use (IMU) in older people

Broadly speaking, medications may be divided into prescription-only (generally more potentially toxic) and ‘over the counter’ (OTC) medications. However, such a distinction may be arbitrary, as people of all ages, including older people, may experience significant problems with abuse of common OTC medications, such as paracetamol and cough mixtures containing codeine.

A more useful distinction may be to divide medications into psychotropic (abuse associated more with neuropsychiatric effects) and nonpsychotropic. The ICD-10 uses the same general principles of intoxication, harmful use, dependence, and withdrawal state that apply to alcohol for use of sedative and hypnotic medications (see Tables 49.2–49.6). As with AUDs, older-specific criteria are not cited, but the same general principles apply: older people are likely to experience harm at lower levels of use and clinical features guiding diagnosis are more likely to be atypical and masked by other health problems.

In addition to incorporating a framework of abuse and dependence for psychoactive agents, the concept of IMU can be further extended to include overuse or potentially inappropriate use of medications (Beers et al., 2000). Overuse occurs when a drug is used when no drug should be used at all. Drug misuse occurs when the wrong drug is used or a drug is used at the wrong dose, at the wrong schedule, or for the wrong duration.

The concept of IMU may be further complicated due to interactions with alcohol (even when taken only at moderate levels or in the context of an AUD) or with illicit drugs. For example, older people on anticoagulant treatment may be unknowingly doing themselves harm, even if their alcohol intake is moderate.

Abuse of illicit substances in older people

ICD-10 defines specific diagnostic criteria for intoxication, harmful use, dependence, and withdrawal state for a wide range of illegal substances, including opioids (heroin), cannabinoids, cocaine, other stimulants including caffeine, hallucinogens, tobacco, and volatile solvents (see Table 49.1).As with AUDs, these diagnostic criteria may not be applicable for older people, as older people may experience harm at lower levels of use, they may not display classical features of craving or compulsion, and intoxication and withdrawal states may be masked by other medical or neuropsychiatric conditions. As with AUDs, low levels of clinical suspicion are likely to apply to older people with illicit drug use.

Epidemiology

Epidemiology of AUDs in older people

AUDs are common in older people and are associated with significant morbidity and mortality. The real prevalence of AUDs in older people is often underestimated, however, for a variety of reasons, as outlined in Table 49.8.

Table 49.8 Reasons for underdetection and misdiagnosis of AUDs in older people

  • Older people and their families and carers reluctant to disclose alcohol use and AUDs

  • Inaccurate recall of alcohol intake due to cognitive impairment

  • Lack of clinical suspicion on the part of healthcare workers

  • Atypical and masked clinical presentation

  • Use of inappropriate screening and diagnostic instruments

  • Recommended levels of alcohol intake inappropriately high for older people

  • Reduced likelihood of referral of older people for specialist AUD treatment

  • Therapeutic pessimism/nihilism

  • Alcohol use and AUDs in later life perceived as ‘a comfort’ and ‘understandable’

High proportions of community-dwelling older people have been reported to drink alcohol. For example, in one study of community-dwelling older people in the US, 62% were found to drink alcohol (Mirand and Welte, 1996). However, levels of alcohol use vary widely between different populations of older people and are likely to be influenced by numerous psychosocial and sociodemographic factors such as age, clinical characteristics, social class, ethnicity, and religion.

There are few systematic studies that have examined the prevalence of alcohol abuse/dependence in people over the age of 65. A recent study (Blazer and Wu, 2011) examining the prevalence of alcohol abuse, dependence, and subthreshold dependence among middle-aged and older people in the US found that about 6.7% (dependence 0.6%, abuse 0.9%, and subthreshold dependence 5.2%) of those older than 65 reported alcohol abuse, dependence, or dependence symptoms. Among past-year alcohol users, 15.4% (dependence 1.3%, abuse 2.1%, and subthreshold dependence 12.0%) of those older than 65 endorsed alcohol abuse or dependence symptoms. ‘Tolerance’ (48%) and ‘time spent using’ (37%) were the two symptoms most frequently endorsed by the subthreshold group.

Rates of recent alcohol use have been noted to decline after the age of 55, to 25% of people aged 85 and older (Ruchlin, 1997) and, in general, levels of alcohol use and the prevalence of AUDs decline with age (Temple and Leino, 1989; Adams et al., 1990, 1995). However, there have also been reports of stable (Ekerdt et al., 1989) or increased (Gordon and Kannel, 1983) levels of alcohol consumption in later life.

The general decline in prevalence of AUDs with age may be due to a number of factors, including the premature deaths of those with early-onset AUDs. Furthermore, age-related changes in pharmacokinetics leading to reduced physiological reserve, along with an increased prevalence of medical conditions and disabilities, may lead to lower levels of alcohol intake in older people. Psychosocial factors such as diminished social networks, social isolation, and financial problems may also lead to reduced alcohol intake, although these factors may conversely lead to increased alcohol intake. An age cohort effect may exist, with the prevalence of AUDs differing between different generations, depending on the sociocultural norms of the time. In the US, for example, individuals reared in the Prohibition era of the 1920s, when alcohol use was outlawed and stigmatized, are likely to drink less than the so-called baby boomer generation who grew up in the more liberal climate of the 1960s and who will start to reach the age of 65 in 2011. AUDs at all levels of severity are far more common in men than women, generally by a factor of four to six times. Other sociodemographic factors may include socioeconomic group and geographical setting (i.e. urban or rural), although these relationships are not clear in older people.

Culture and ethnicity are important associations of AUDs in general adult populations and these factors are also likely to be important in older people. Therefore levels of AUDs are likely to be lower in religious and ethnic groups where alcohol use is strictly sanctioned or not allowed, such as among Muslims and Orthodox Jews. In the UK, alcohol-related mortality may be marginally elevated in people of Caribbean origin, and is substantially higher in people of Irish and Indian origin (Harrison et al., 1997).

The prevalence of AUDs in older people also varies depending on the restrictiveness of diagnostic criteria used and the clinical and sociodemographic characteristics of the population being studied. For example, the prevalence rate for ‘excessive alcohol consumption’ in a particular population will be higher than that for alcohol dependence syndrome. Community-based studies estimate the prevalence of alcohol misuse or dependence among older people as 2–4% (Adams and Cox, 1995), with much higher rates of 16% (men) and 2% (women) when looser criteria such as excessive alcohol consumption are used (UK Datasets, 1994; Greene et al., 2003). Likewise, the prevalence of AUDs is higher in clinical populations such as medical and psychiatric inpatients than among primary care attendees and normal community-dwelling populations. For example, the prevalence of AUDs is higher among older inpatients, with estimates of 14% for emergency department patients (Adams et al., 1992), 18% for nursing home residents (Joseph et al., 1995), and 23% for psychiatric inpatients (Speer and Bates, 1992).

It has been estimated that two-thirds of older people with AUDs started drinking at a younger age, with the remaining one-third having ‘late-onset’ AUDs (Council on Scientific Affairs, 1996). Apart from the timing of onset of AUD, other key differences, with implications for clinical outcome, have been noted to exist between these two groups: individuals with early-onset AUDs are more likely to have a positive family history of AUDs, antisocial personality traits, and more severe AUDs with greater associated damage to their physical and psychological health and social networks. As a result, individuals with early-onset AUDs may be more difficult to engage in treatment (Liberto and Oslin, 1995). In contrast, those with late-onset AUDs may have higher levels of income and education and more circumscribed AUDs triggered by discrete stressful life events such as bereavement or retirement (LaGreca et al., 1988). There is evidence to suggest that those with late-onset AUDs have better clinical outcomes (Schutte et al, 1994).

Epidemiology of IMU in older people

Older people receive more prescriptions than any other age group, and are also more likely to be dispensed multiple drug regimens (Patterson and Jeste, 1999; McGrath et al., 2005). For example, although older people comprise 13% of the US population, they have been estimated to use more than 30% of prescription drugs (Williams and Lowenthal, 1992; Avorn, 1995) and 35% of OTC drugs (Williams and Lowenthal, 1992). It has been estimated that older people use prescription and OTC medications approximately three times as much as the general population and that the estimated annual expenditure on prescription drugs by older people is four times that of younger people (Anderson et al., 1993; Jeste and Palmer, 1998). While polypharmacy may be appropriate and clinically indicated in older people, the risk of adverse drug reactions has been reported to double when utilization increases from one to four medications, and the risk increases 14-fold when seven drugs are used (Cadieux, 1989; Chrischilles et al., 1992). It has been estimated that older people in the US use 5.8 prescription drugs concurrently along with 3.2 OTC drugs (Williams and Lowenthal, 1992; Sintonen, 1994; Avorn, 1995).

In a large US retrospective cohort study involving 493,971 inpatients (Rothberg et al., 2008), 49% received at least one potentially inappropriate medication and 6% received three or more. Patient, physician, and hospital characteristics were all associated with potentially inappropriate medication use.

These high levels of medication use, along with age-related impairments in pharmacokinetics, the high levels of polypharmacy (either appropriate or not), and the fact that older people are more likely to be on long-term medications (e.g. antidiabetic or cardiovascular medication) as opposed to short-term medications (e.g. a single course of antibiotics) than is the case in younger people, mean that older people are far more likely to experience an adverse drug event than younger people, even when medications are taken as directed. Added to this (as outlined in the section Epidemiology of AUDs in older people), medications may be overused, underused, used inappropriately, or used in combination with substances such as alcohol or illegal drugs that may lead to harmful drug interactions.

Benzodiazepines are the most commonly prescribed psychotropic drugs in older people, with one study of community-dwelling older people in Ireland demonstrating that 17% of participants were prescribed benzodiazepines, with use in women being twice that in men, and 18% of benzodiazepine users taking at least one other psychotropic drug. Furthermore, 52% of benzodiazepine users were prescribed a long-acting benzodiazepine (Kirby et al., 1999a). It has also been reported that depression in older community-dwelling people is more likely to be detected if accompanied by anxiety symptoms, and such individuals are at risk of inappropriate treatment with benzodiazepines (Kirby et al., 1999b).

In another study, the prevalence of psychotropic drug misuse was reported to be four times greater in women than in men, and other associations demonstrated included widowhood, lower educational level, lower income, poorer health, and reduced social support (King et al., 2003).

Abuse of prescription drugs (most often sedative-hypnotic, anxiolytic, and analgesic) has been reported to account for 5% of community-dwelling older mental health clinic attendees (Jinks and Raschko, 1990), and 30% of residents of intermediate care facilities were reported as being prescribed long-acting drugs not recommended for older people (Beers et al., 1988).

Misuse of drugs in older people due to poor prescribing practices is also a significant public health problem, with 20% of community-dwelling older people receiving a drug considered inappropriate by experts and 40% of nursing home residents receiving inappropriate medication (Avorn and Gurwitz, 1995).

Use of opiate analgesia is common in older people and is liable to give rise to inappropriate use and problems with addiction. Therefore, use of these medications should be closely monitored, with due consideration of dose, duration of treatment, and careful tapering (Schneider, 2005). During the 8-year period of 1995–2002, admission for substance use treatment increased 32% for people over the age of 65 in the US. While the most common drug of abuse was alcohol, the number of older Americans reporting opiates as their primary drug of abuse increased from 6.8% to 12% (Office of Applied Studies, 2005).

Epidemiology of use of illicit drugs

Lifetime prevalence rates for illicit drug dependence have been estimated as 17% for 18- to 29-year-olds, 4% for 30- to 59-year–olds, and less than 1% for those over the age of 60 (Hinkin et al., 2002). Lifetime experience of cannabis in the 65- to 69-year-old age group in the UK has been reported to be 7 per 1000 (Lawlor et al., 2003). The Epidemiological Catchment Area (ECA) study found that less than 0.1% of older people (over age 65) met DSM-III criteria for illegal drug abuse or dependence in the previous month (Regier et al., 1988), with corresponding rates for the same period of 3.5% for 18- to 24-year-olds. ECA data suggest a lifetime prevalence rate for illicit drug use of only 1.6% for older people (Anthony and Helzer, 1991). In the 2009 National Survey on Drug Use and Health (NSDUH) report from the US (Office of Applied Studies, 2009, during the past year nonmedical use of prescription drugs was more common than marijuana use among those over age 65 (0.8% vs 0.4%); however, the rate of marijuana use for ‘baby-boomers’ (those over age 50) was much higher at 4.2%, and we can therefore expect a rise in the incidence and prevalence of illicit drug use in older people by 2020 as this population ages.

Several other sources of data suggest similarly low rates of illegal drug use among older people. However, the ageing of the ‘baby-boomer’ generation is likely to result in a cohort of older people who are healthier and have higher life-expectancies than previous generations of older people, but who also carry with them higher rates of illegal drug use (Patterson and Jeste, 1999). The findings of Amdt and colleagues (2011) demonstrating that the proportion of older adults (defined as 55 years or over in the study) attending for substance use treatment is increasing relative to younger adults, with an increasing illicit drug involvement (cocaine and heroin) in older adult admissions, are consistent with a cohort effect of ‘baby-boomers’.

Aetiology, Risk Factors, and Associations

The aetiology, risk factors, and associations of AUDs, IMU, and illegal substance use disorders all involve complex interactions among several factors. These factors may be described as being distal (e.g. positive family history of AUD) as opposed to proximal (e.g. recent bereavement leading to excessive drinking), they may be thought of as being fixed (e.g. female gender and risk of IMU) as opposed to modifiable (e.g. rationalizing prescribed medication may reduce the risk of IMU), or they may be thought of as being biological/medical (e.g. age-related pharmacokinetic changes leading to relatively higher alcohol toxicity and increased risk of AUD), social (e.g. unemployed or divorced status and risk of AUDs), or psychological (e.g. antisocial personality traits or depression and risk of AUDs) in nature. Finally, risk factors can also be described in another three broad groupings: predisposing factors; factors that may increase substance exposure and consumption level; and factors that may increase the effects and abuse potential of substances (see Table 49.9).

Table 49.9 Risk factors for substance abuse in older people

Predisposing factors

Family history (alcohol)

Previous substance abuse

Previous pattern of substance consumption (individual and cohort effects)

Personality traits (sedative-hypnotics, anxiolytics)

Factors that may increase substance exposure and consumption level

Gender (men—alcohol, illicit drugs; women—sedative-hypnotics, anxiolytics)

Chronic illness associated with pain (opioid analgesics), insomnia (hypnotic drugs), and anxiety (anxiolytic)

Long-term prescribing (sedative-hypnotics, anxiolytics)

Caregiver overuse of ‘as needed’ medication (institutionalized older people)

Life stress, loss, social isolation

Negative affects (depression, grief, demoralization, anger) (alcohol)

Family collusion and drinking partners (alcohol)

Discretionary time, money (alcohol)

Factors that may increase the effects and abuse potential of substances

Age-associated drug sensitivity (pharmacokinetic, pharmacodynamic factors)

Chronic medical illnesses

Other medications (alcohol–drug, drug–drug interactions)

Aetiology, risk factors, and associations of AUDs in older people

Biological/medical factors

While the genetics of AUDs is complex, involving the interaction of several genes (Buckland, 2001), we know that positive family history is a risk factor for AUDs in the general population and is also likely to be important in older people, in relation to both early-onset (Dahmen et al., 2005) and late-onset (Tiihonen et al., 1999) AUDs. The genetic risk for AUDs may also overlap with risk for other mental disorders, such as antisocial personality disorder, other drug use problems, anxiety disorders, and mood disorders (Nurnberger et al., 2004).

The higher prevalence of AUDs seen in clinical populations such as medical and psychiatric inpatients (see Epidemiology) implies that AUDs may arise as a consequence of medical conditions or indeed may play a part in the aetiology and perpetuation of medical conditions.

Age-related changes in pharmacokinetics and reductions in physiological reserve also mean that older people are more likely to encounter problems associated with alcohol intake even when consumed at moderate levels, along with having an increased risk of developing alcohol–drug interactions (National Institute on Alcohol Abuse and Alcoholism, 1998).

Social factors

Social factors are involved in the aetiology of AUDs in older people as in all age groups, and these factors may have a two-way relationship with the development of AUDs (i.e. play a causative role in the development of the AUD or arise as a consequence of the AUD).

Male gender is invariably found to be a risk factor for AUDs in all age groups and cultures, and this may simply reflect prevailing societal norms of heavier drinking among men that lead to an increased risk of developing AUDs. However, social characteristics may also reflect underlying biological/medical and psychological risk factors and associations (e.g. increased risk of AUDs in men may reflect their higher levels of antisocial personality disorder, a risk factor for AUDs in itself).

An age cohort effect may also exist, with the prevalence of AUDs differing between generations, depending on the sociocultural norms of the time. Other important social factors include culture, ethnicity, social isolation, and marital status (sees Epidemiology, and Ekerdt et al., 1989; Bristow and Clare, 1992; Ganry et al., 2000).

Psychological factors

Personality types and traits associated with AUDs may differ between ‘early-onset’ and ‘late-onset’ types. The ‘early-onset’ type may have a stronger association with antisocial personality traits, hyperactivity, and impulsivity. ‘Late-onset’ AUDs may have a stronger relationship with ‘neuroticism’ and depression (Mulder, 2002). Furthermore, there is emerging evidence that the personalities of lifelong nondrinkers may differ from those of moderate drinkers, being more introverted and more neurotic, thus explaining their poorer physical and psychological health characteristics as they appear on the J-shaped curve (O’Connell et al., 2005).

AUDs in older people, as in all populations, may also have a two-way relationship with psychiatric disorders such as depression and anxiety disorders. For example, older people may begin drinking in an effort to self-medicate depressive symptoms, or they may become depressed because of their drinking (Davidson and Ritson, 1993). Previous history of alcohol use or AUD is also important, as an individual with a resolved AUD from the past may relapse in later life in the context of changes in health characteristics or life circumstances.

AUDs are involved in the aetiology of cognitive impairment and dementia (see Clinical Features and Comorbidity), although the precise mechanisms are complex and not fully clear. However, clinical experience suggests that symptoms of AUDs may also be the first presenting problems of cognitive impairment or dementia in older people.

Aetiology, risk factors, and associations of IMU in older people

The general principles for aetiology, risk factors, and associations for substance misuse outlined in the previous section (see Table 49.9) apply to IMU. The much higher exposure of older people to prescribed medications (see Epidemiology) along with age-related pharmacokinetic changes and comorbid medical and neuropsychiatric conditions all interact to heighten the risk of IMU in older people.

Biological and medical factors in the development of IMU may include genetic predisposition (phenotypes associated with other factors such as alcohol dependence, illicit drug use, and antisocial personality disorder (Nurnberger et al., 2004)), cognitive impairment, chronic medical conditions requiring long-term prescribing of medication such as pain (Helme and Katz, 1993), and age-related pharmacokinetic changes leading to an increased likelihood of developing adverse reactions to medication use (Beers et al., 2000). There may also be adverse drug interactions between prescribed medications and alcohol.

The type of medication prescribed is also an important consideration. For example, benzodiazepines are among the medications most commonly implicated in IMU in older people, and the risk of IMU with benzodiazepines increases with higher drug potency, shorter elimination half-life, and longer duration of prescription (Kirby et al., 1999). The high prevalence of pain (estimated at 20–50% in community-dwelling older people: Barkin et al., 2005) means that analgesics such as nonsteroidal agents and opiates are likely to be misused in older people and lead to the development of IMU.

Psychosocial factors identified to be associated with IMU include older age, female gender, white race, lower educational level, and separated or divorced status (Swartz et al., 1991). Other mental disorders associated with benzodiazepine dependence in the general population, and also likely to be relevant to older people, include depression, panic disorder, AUDs and abuse of other substances, generalized anxiety disorder, and personality disorders (Swartz et al., 1991; Busto et al., 1996).

Aetiology, risk factors, and associations of illicit drug use in older people

Predictably, older opioid maintenance patients have been reported to have significantly more medical problems and worse general health, along with a later onset of use of illicit substances, than younger opioid patients (Lofwall et al., 2005), and these findings are also likely to apply to older people who use other illegal drugs. Certain illegal drugs may be associated with particular conditions, such as the association seen between pain and abuse of opioids (Trafton et al., 2004). As with AUDs and IMU, genetic factors may play a role in the aetiology of illegal drug use in the general population and in older people (Kuhar et al., 2001).

Important social factors may include gender (male gender is associated with higher risk of illegal drug use), socioeconomic status, and level of social supports and networks. Age cohort is also likely to be important, with ‘baby-boomers’ identified as carrying with them into later life a higher prevalence of illegal drug use than previous generations of older people (Patterson and Jeste, 1999; Amdt et al., 2011).

Use of illegal drugs in the general population is associated with an increased prevalence of psychiatric illnesses and personality disorders, and this is also likely to be the case in older populations.

Clinical Features and Comorbidity

Clinical features and comorbidity in AUDs in older people

AUDs in older people are associated with significant morbidity and mortality, affecting practically all aspects of physical, neuropsychiatric, and social health and wellbeing, as summarized in Table 49.10 (Reid and Anderson, 1997; O’Connell et al., 2003a).

Physical aspects

Practically every organ system may be adversely affected by AUDs in older people, as outlined in Table 49.10. Pharmacokinetic changes in older people, with reduced physiological reserve, reduced metabolic efficiency, and an increased volume of distribution due to a higher fat to lean muscle ratio, mean that alcohol intake in older people leads to relatively higher blood alcohol concentrations (Dufour and Fuller, 1995; Kalant, 1998). This increase in blood alcohol concentration is associated with a higher risk of intoxication and harmful effects. Furthermore, even when blood alcohol concentration is controlled for, alcohol-induced impairment in task performance has been demonstrated to increase with advancing age (Vogel-Sprott and Barrett, 1984).

These pharmacokinetic changes, along with the general effects of physical and cognitive ageing, increasing frailty, reduced functional ability, and higher levels of concomitant prescription drug use, mean that alcohol is relatively more toxic to older people than younger people. Furthermore, such toxic effects may be subtle and may be missed or mistaken for other conditions.

Neuropsychiatric aspects

AUDs in older people are associated with a wide range of mental disorders, such as depression, psychosis, withdrawal syndromes, cognitive impairment, and dementia (see Table 49.10). The relationship between alcohol use and brain damage and dementia is complex (Nieman, 1998; Fig. 49.1): AUDs may increase the risk for many types of dementia (Letenneur, 2004) and there also exist diagnostic entities known as ‘alcohol-induced persisting dementia’ (Table 49.11) and an amnesic syndrome associated with alcohol use (Table 49.12), while light–moderate alcohol use may protect against dementia (Ruitenberg et al., 2002). Sulcal widening and ventricular enlargement have been cited as the strongest neuropathological findings in patients with ‘alcohol-induced dementia’, with additional evidence for peripheral neuropathy, ataxia, sparing of language, and improved prognosis when compared to other types of dementia (Smith and Atkinson, 1995).

Fig. 49.1 Relationship between AUDs and dementia.

Fig. 49.1
Relationship between AUDs and dementia.

Table 49.11 DSM-IV diagnostic criteria for alcohol-induced persisting dementia (APA, 1994)

  1. A. The development of multiple deficits manifested by both:

    1. 1. Memory impairment (impaired ability to learn new information or to recall previously learned information); and

    1. 2. One or more of the following cognitive disturbances:

      1. (a) aphasia (language disturbance);

      1. (b) apraxia (impaired ability to carry out motor activities despite intact motor function);

      1. (c) agnosia (failure to recognize or identify objects despite intact sensory function); and/or

      1. (d) disturbance in executive functioning (i.e. planning, organization, sequencing, abstracting).

  1. B. The cognitive deficits in criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.

  1. C. The deficits do not occur exclusively during the course of a delirium and persist beyond the usual duration of alcohol intoxication or withdrawal.

  1. D. There is evidence from the history, physical examination, and laboratory findings that the deficits are aetiologically related to the persisting effects of alcohol use.

Table 49.12 Amnesic syndrome (due to alcohol or other substances) (WHO, 1992)

  1. A. Memory impairment is manifest in both:

    1. (1) a defect of recent memory (impaired learning of new material) to a degree sufficient to interfere with daily living; and

    2. (2) a reduced ability to recall past experiences.

  2. B. All of the following are absent (or relatively absent):

    1. (1) defect in immediate recall (as tested, e.g., by the digit span);

    2. (2) clouding of consciousness and disturbance of attention, as defined in F05, criterion A, of ICD-10;

    3. (3) global intellectual decline (dementia).

  3. C. There is no objective evidence from physical and neurological examination, laboratory tests, and history of a disorder or disease of the brain (especially involving bilaterally the diencephalic and medial temporal structures), other than that related to substance use, which can reasonably be presumed to be responsible for the clinical manifestations described under criterion A.

There are several ways in which AUDs may cause cognitive impairment and dementia (Fig. 49.1). AUDs may indirectly increase the risk for vascular dementia and Alzheimer’s dementia by increasing vascular risk factors, and these conditions probably account for the majority of cognitive impairment and dementia seen in older people with AUDs. However, there is also significant epidemiological evidence demonstrating reduced risk of dementia in light and moderate drinkers, although the underlying mechanisms for this relationship are yet to be elucidated (Anstey et al., 2009). AUDs are also associated with the Wernicke–Korsakoff syndrome, an amnestic syndrome arising from thiamine deficiency due to AUDs or other causes.

AUDs in older people are frequently associated with other psychiatric disorders, most commonly depression. There may be a two-way interaction between mental disorders and alcohol use. For example, an individual with depression may begin to drink excessively, or excessive drinking may lead to depression (Davidson and Ritson, 1993). Thus, comorbidity may arise as a result of cause or effect, i.e. older individuals who develop psychological problems in later life may drink alcohol as a form of ‘self-medication’ (i.e. ‘late-onset’ AUD; see Epidemiology), and put themselves at risk of developing an AUD, or individuals with AUDs may develop psychiatric disorders because of the physical, cognitive, or social consequences of their drinking. In general terms, the nature and severity of psychiatric comorbidity is likely to differ between those with early- and those with late-onset AUDs, with the early-onset group having higher levels of antisocial personality traits, a stronger family history, and more severe and complicated AUDs.

The Liverpool longitudinal community study (Saunders et al., 1991) demonstrated that older men with a history of heavy drinking for 5 years or more at some time in their lives had a greater than five-fold increased risk of suffering from a psychiatric disorder. Furthermore, it was concluded that those with a current psychiatric diagnosis had significantly higher alcohol consumption, and the association between heavy alcohol consumption in earlier years and psychiatric morbidity in later life was not simply explained by current drinking habits.

In the US, data from the National Longitudinal Alcohol Epidemiologic Survey demonstrated that major depression is three times more common in the over 65s who have an AUD compared to those who do not (Grant and Harford, 1995), and in another survey, 30% of an older population with AUDs were found to have concurrent psychiatric disorders (Moos et al., 1998). These high levels of comorbidity are also reflected in the observation that up to 50% of older psychiatric inpatients have been noted to be heavy users of alcohol (Atkinson and Schuckit, 1983; McGrath et al., 2005).

Depression in older people with AUDs has a more complicated clinical course and has been demonstrated to be more severe and chronic in nature than depression without AUDs (Cook et al., 1991). Such individuals may be less likely to present to or engage with mental health services and may be less compliant with any treatment strategies introduced.

Other psychiatric disorders, such as anxiety disorders and psychotic disorders, are also important but less common comorbidities of AUDs in older people.

In view of the high degree of psychiatric comorbidity associated with AUDs in older people, it is not surprising that AUDs in older people are also strongly associated with suicide, due to interaction between the effects of drinking and other health factors such as depressive symptoms, medical illness, negatively perceived health status, and low social support (Blow et al., 2004). In a Swedish retrospective case-control study, alcohol dependence or misuse as defined by DSM-IV was present in 35% of male and 18% of female suicides, in comparison to only 2% of male and 1% of female controls (Waern, 2003).

It must also be borne in mind that, even in the absence of a clinically diagnosable AUD, the neuropsychiatric effects of alcohol intoxication (emotional changes, disinhibition, impulse dyscontrol, impaired judgement, and increased propensity for violent self-harm) may increase suicide risk: alcohol intoxication may be part of the individual’s suicide plan, or intoxication may lead on to suicidal behaviour, particularly if the individual is currently experiencing psychological distress (O’Connell and Lawlor, 2005a).

Clinical features and comorbidity in IMU in older people

Clinical features and comorbidities associated with IMU in older people will vary widely depending on the drug being used and patient characteristics, such as age, gender, and presence of other physical and neuropsychiatric problems. An outline of clinical features and comorbidities is given in Table 49.13. The most common reported adverse consequence of inappropriate medication use has been increased risk of falls, usually due to long-acting benzodiazepines and medications with anticholinergic properties (Berdot et al., 2009).

Table 49.13 Clinical features and comorbidity associated with inappropriate medication use in older people

Neuropsychiatric (all psychotropic drugs; benzodiazepines particularly prevalent)

Delirium

Day-time drowsiness

Sleep disturbance

Depression

Anxiety

Physical

Falls

Fractures

Drug–drug and drug–alcohol interactions

Problems related to drug metabolism (e.g. renal and hepatic impairment)

Clinical features and comorbidity of illicit drug use in older people

As outlined in the section Epidemiology, illicit drug use is uncommon in current and past cohorts of older people and there is thus a dearth of information on clinical features and comorbidity. Such features will also vary widely depending on the drug in question and the mode of administration. For example, an older smoker of marijuana is likely to have different clinical features and comorbidities from an older intravenous heroin user. As with AUDs and IMU, clinical features of illegal drug use in older people may be atypical and masked by other conditions, and problems are likely to arise at lower levels of drug use, due to reduced physiological reserve, pharmacokinetic changes, and comorbid physical and neuropsychiatric conditions.

Clinical Assessment, Investigations, and Screening

Clinical assessment, investigations and screening in AUDs

Clinical assessment

The assessment of AUDs in older people should be based on the standard clinical interview, mental state examination, physical examination, and collateral history, if available and with the patient’s consent. The standard interview and examination should be supplemented by specific questions relating to alcohol use, keeping in mind the potentially subtle and atypical nature of AUDs in older people. Questions should be framed in a sensitive and nonjudgemental way, as patients may disengage and be lost to treatment and follow-up if they feel threatened by the assessment procedure.

The history should involve questions about current and past levels of alcohol use, frequency and quantity of intake, the types of alcoholic beverage consumed, and the context in which drinking takes place. Changes in levels of intake may be significant, and should be interpreted in the context of the overall history. For example, while older individuals may have reduced their level of alcohol intake in recent years, suggesting that they have no current AUD, this reduction may have occurred due to decreased tolerance to the effects of alcohol on a background history of a chronic AUD, and the person may continue to experience alcohol-related problems even at this lower level of intake.

Specific questions relating to the features of alcohol intoxication (Table 49.2), harmful use (Table 49.3), alcohol dependence (Tables 49.4 and 49.5), and a previous history of alcohol withdrawals (Table 49.6) should be asked if indicated by the initial history and examination, along with specific questions relating to AUDs in older people (see Table 49.10). Concomitant medication and illegal drug use should be recorded. A family history of psychiatric illness should be elicited, focusing especially on AUDs and mood disorders. Relevant aspects of the personal and social history include early life experiences and exposure to AUDs in others, age of onset of drinking, occupational record, relationship history, and legal or forensic problems.

Table 49.6 ICD-10 criteria for withdrawal state

  1. G1. There must be clear evidence of recent cessation or reduction of substance use after repeated, and usually prolonged and/or high-dose, use of that substance.

  • G2. Symptoms and signs are compatible with the known feature of a withdrawal state for the particular substance or substances.

  • G3. Symptoms and signs are not accounted for by a medical disorder unrelated to substance use, and not better accounted for by another mental or behavioural disorder.

The mental state examination should take into account level of alertness and a preliminary cognitive assessment or cognitive screening measure (e.g. Mini-Mental State Examination: Folstein et al., 1975); current mood state; any evidence of psychosis; ideas of hopelessness, suicide, or deliberate self-harm; and psychiatric manifestations of alcohol withdrawal (Table 49.6).

The physical examination should include recording of vital signs such as blood pressure, pulse, temperature, and respiratory rate. Objective evidence of acute alcohol withdrawals should be recorded. A more detailed physical examination should be performed if indicated, focusing on the different organ systems involved in AUDs (see Table 49.10).

A collateral history is also very valuable for the overall assessment, as people may underestimate their level of alcohol intake and associated AUD either deliberately, because of embarrassment and reluctance to engage in treatment, or because of faulty recall related to cognitive impairment.

Investigations

Following a detailed history and examination, other investigations may be indicated and should be directed by the patient’s clinical status. For example, an individual admitted for treatment of alcohol withdrawals will require blood tests to check at least the following: urea and electrolytes; full blood count; liver function tests; vitamin B12 and folate levels. Further investigations may also be indicated, depending on the clinical findings and the organ system involved (Table 49.10). These may include the following: neuroimaging (CT or MRI brain); gastrointestinal investigations such as ultrasound, CT, or MRI examinations of the abdomen, upper gastrointestinal endoscopy, and liver biopsy; basic cardiovascular investigations such as electrocardiogram and other more detailed investigations if indicated, e.g. echocardiogram and 24-h blood pressure monitoring.

Further psychological investigations include detailed neuropsychological assessment of cognition if impairment is detected in the initial assessment (as outlined in Clinical assessment). Psychological assessment may also be required to assess for patient suitability and level of motivation for addiction counselling or other psychotherapeutic interventions.

Social investigations include more detailed collateral histories if available, along with an assessment of financial status, social supports, and accommodation arrangements.

Screening

As already alluded to throughout this chapter, screening for AUDs in older people should focus on the broad spectrum of such problems and not merely clear-cut cases such as the ‘down and out’ alcoholic. Screening should also aim to detect the subtler but also damaging effects of AUDs in older people, such as drinking moderately while taking medications that interact with alcohol.

The main methods of screening used in older people involve self-report screening measures, such as the CAGE (Ewing, 1984) and the Alcohol Use Disorders Identification Test (AUDIT; Saunders et al., 1993), and older-specific versions of self-report instruments, such as the Michigan Alcohol Screening Test – Geriatric Version (MAST-G; Blow, 1991), along with biophysical measures, such as blood tests checking mean corpuscular volume and liver function tests. In practice, different screening measures are often used in the assessment of an individual. It is important to point out that screening instruments are designed to detect at-risk individuals, but they are not diagnostic tools in themselves, their use may yield false-positives and false-negatives, and they should not serve as a substitute for a thorough clinical interview and examination.

A systematic review of self-report alcohol screening instruments in older people (O’Connell et al., 2004) found that the CAGE (Ewing, 1984) was the most widely studied instrument, followed by the MAST (Selzer, 1968) and variations of the MAST, the AUDIT (Saunders et al., 1993) and variations of the AUDIT, and others. Sensitivity and specificity of self-report alcohol screening instruments was found to vary widely, depending on the prevalence of AUDs in the population under study, the clinical characteristics of the population, and the type of AUD being detected. The Cyr–Wartman (Cyr and Wartman, 1988) and CAGE questionnaires are the briefest tests and can be administered in less than 30 s, making these screening instruments the easiest to use. Far more research has focused on the CAGE, and its sensitivity and specificity in older people are superior to those of the Cyr–Wartman questionnaire. Despite the advantage of ease of use of the CAGE, deficiencies were highlighted in a number of studies of older populations, and the AUDIT-5 (Philpot et al., 2003), another brief test, may prove to be more useful in older people with psychiatric illness. The Alcohol-Related Problems Survey (ARPS) and its shortened version (shARPS) (Fink et al., 2002) may prove to be more useful in older people with medical comorbidity, but their use is limited by the fact that they take, respectively, 10 and 9 min to apply.

A recent Finnish study (Aalto et al., 2011) examining the utility of the AUDIT and its derivatives in screening for heavy drinking in older people found that the AUDIT and AUDIT-C are accurate if the cut points are tailored to this age group (cut points of 4 or more on AUDIT-C and 5 or more on AUDIT).

In order to use AUD screening in routine clinical practice, the demographic characteristics of the target population are an important consideration. For example, routinely screening all older women attending an active retirement centre may yield few cases of AUDs, but it may prove to be a costly and intrusive exercise. However, screening of high-risk populations, such as older medical and psychiatric inpatients (see section Epidemiology) is advised, as this practice may yield high levels of AUDs that direct the development of appropriate and much-needed treatment services. Furthermore, ease of use, patient acceptability, and sensitivity and specificity of the screening instrument must all be taken into consideration.

As with self-report screening instruments, the utility of biophysical screening measures such as carbohydrate-deficient transferrin, liver function tests, or the mean corpuscular volume may be less reliable in older people (Luttrell et al., 1997), because of higher levels of comorbid physical illnesses leading in themselves to abnormal results.

Clinical assessment, investigations, and screening for IMU in older people

Clinical assessment

As with AUDs, a standard clinical assessment involving a history, mental state and physical examination, and collateral history should be performed. Prescription drug abuse of benzodiazepines and opiates can be difficult to detect in older people, and effects of abuse such as irritability, depression, drowsiness, and memory lapses can be falsely attributed to normal ageing. A list of all prescribed and OTC medications being used, along with their indications for use, should be recorded. Ideally, patients should be asked to bring with them all medications in their containers, as this will also give an indication as to levels of adherence or compliance. Any reported adverse effects should be recorded, along with symptoms and signs indicating underuse, overuse, or intermittent use of medication. Clinical features will vary depending on the medications being used.

Investigations

Blood levels of some prescribed medications may be checked in order to assess levels of compliance and to establish if the blood level is within the therapeutic window for the drug in question (e.g. lithium, carbamazepine). Other biophysical measures may also be indicated that provide proxy measures of medication compliance, such as random or fasting glucose levels and levels of glycosylated haemoglobin, to assess for level of diabetes control and compliance with hypoglycaemic agents or insulin.

Screening

There are no routinely used screening measures for IMU in older people. Clinicians should have a high index of suspicion for prescription abuse where an older person is on benzodiazepines or opiates and has ongoing symptoms of pain, depression, or anxiety, or is complaining of adverse side effects such as drowsiness, falls, memory loss, and confusion. The use of a measure such as Beers’ criteria (Beers, 1997) may be a useful addition to the overall assessment of an older person if potentially inappropriate use of medication is suspected. In a study updating Beers’ criteria (Fick et al., 2003), a modified Delphi method was used, which is a set of procedures and methods for formulating a group judgement for a subject matter in which precise information is lacking. Identified were 48 individual medications or classes of medications to avoid in older adults and 20 diseases/conditions and medications to be avoided in older adults with these conditions (Tables 49.14 and 49.15). Sixty-six of the inappropriate medications identified were considered by the panel to have adverse outcomes of high severity. The STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) has recently been demonstrated to be superior to Beers’ criteria when applied to acutely ill older medical inpatients (Gallagher and O’Mahony, 2008).

Table 49.14 Criteria for potentially inappropriate medication use in older adults: independent of diagnoses and conditions (Fick et al., 2003)

Drug

Concern

Severity rating (high or low)

Propoxyphene (Darvon) and combination products (Darvon with ASA, Darvon-N, Darvocet-N)

Offer few analgesic advantages over acetaminophen, yet have the adverse effects of other narcotic drugs.

Low

Indomethacin (Indocin, Indocin SR)

Of all available NSAIDs, this drug produces the most CNS adverse effects.

High

Pentazocine (Talwin)

Narcotic analgesic that causes more CNS adverse effects, including confusion and hallucinations, more commonly than other narcotic drugs. Additionally, it is a mixed agonist and antagonist.

High

Trimethobenzamide (Tigan)

One of the least effective antiemetic drugs, yet it can cause extrapyramidal adverse effects.

High

Muscle relaxants and antispasmodics: methocarbonal (Robaxin), carisoprodal (Soma)chlorozoxazone (Paraflex), meaxalone (Skelaxin), cyclobenzaprine (Flexeril), oxybutynin (Ditropan). Do not consider the extended-release Ditropan XL.

Most muscle relaxants and antispasmodic drugs are poorly tolerated by older patients, since these cause anticholinergic adverse effects, sedation, and weekness. Additionally, their effectiveness at doses tolerated by older patients is questionable.

High

Flurazepam (Dalmane)

This benzodiazepine hypnotic has an extremely long half-life in older patients (often days), producing prolonged sedation and increasing the incidence of falls and fracture. Medium- or short-acting benzodiazepines are preferable.

High

Amitriptyline (Elavil), chlorodiaazepaxide-amitriptyline (Limbitrol), perphenazine-amitriptyline (Triavil)

Because of its strong anticholinergic and sedation properties, amitriptyline is rarely the antidepressant of choice for older patients.

High

Doxepin (Sinequan)

Because of its strong anticholinergic and sedation properties, doxepin is rarely the antidepressant of choice for older patients.

High

Meprobamate (Miltown, Equanil)

This is a highly addictive and sedating anxiolytic. Those using meprobamate for prolonged periods may become addicted and may need to be withdrawn slowly.

High

Doses of short-acting benzodiazepines (doses greater than): larazepam (Ativan) 3 mg; oxazepam (Serax) 60 mg; alprozolam (Xanax) 2 mg; tenazepam (Restoril) 15 mg; triazolam (Halcion) 0–25 mg

Because of increased sensitivity to benzadiazepines in older patients, smaller doses may be effective as well as safer. Total daily doses should rarely exceed the suggested maximums.

High

Long-acting benzodiazepines: chlorodiazepoxide (Libriurn), chlordiazepoxide-amitriptyline (Limbitrol) clidinium-chlorodiazepaxide (Librax), diazepam (Valium), quazepam (Doral), halasepam (Paxipam), chlorazepate (Tranxene)

Have a long half-life in older patients (often several days), producing prolonged sedation and increasing the risk of falls and fractures. Short- and intermediate-acting benzodiazepines are preferred if a benzodiazepine is required.

High

Disopyraximide (Norpace, Norpace CR)

Of all the antiarrhrythmic drugs, this is the most potent negative inotrope and therefore may induce heart failure in older patients. It is also strongly anticholinergic. Other antiarrhythmic drugs should be used.

High

Digoxin (Lanoxin) (should not exceed 〉 0.125 mg/day except when treating atrial arrhythmias)

Decreased renal clearance may lead to increased risk of toxic effects.

Low

Short-acting dipyridamole (Persantine). Do not consider the long-acting dipyridamole (which has better properties than the short-acting in older adults) except with patients with artificial heart valves

May cause orthostatic hypotension.

Low

Methyldopa (Aldomet) and methyldopa-hydrochlonothiazide (Aldoril)

May cause bradycardia and exacerbate depression in older patients.

High

Reserpine at doses 〉 0.25 mg

May induce depression, impotence, sedation, and orthostatic hypotension.

Low

Chlorpropamide (Diabinese)

Has a prolonged half-life in older patients and could cause prolonged hypoglycaemia. Additionally, it is the only oral hypoglycaemic agent that causes SIADH.

High

Gastrointestinal antispasmodic drugs: dicyclomine (Bentyl), hyoscyamine (Levsin and Levsinex), propantheline (Pro-banthine), belladonna alkaloids (Donnatal and others), clidinium-chlordiazepoxide (Librax)

Highly anticholinergic and have uncertain effectiveness. These drugs should be avoided (especially for long-term use).

High

Anticholinergics and antihistamines: chloropheniramine (Chlor-Trimetan), diphenhydramine (Banadryl), hydroxyzine (Vistaril and Atarax), cyproheptadine (Periactin), promethazine (Phenergan), tripellannamine, dexchlorpheniramine (Polaramine)

All nonprescription and many prescription antihistamines may have potent anticholinergic properties. Nonanticholinergic antihistamines are preferred in older patients when treating allergic reactions.

High

Diphenhydramine (Benadryl)

May cause confusion and sedation. Should not be used as a hypnotic, and when used to treat emergency allergic reactions, it should be used in the smallest possible dose.

High

Ergot mesyloids (Hydergine) and cyclandelate (Cyclospasmol)

Have not been shown to be effective in the doses studied.

Low

Ferrous sulphate more than 325 mg/day

Doses more than 325 mg/day do not dramatically increase the amount absorbed but greatly increase the incidence of constipation.

Low

All barbiturates (except phenobarbital) except when used to control seizures

Highly addictive and cause more adverse effects than most sedative or hypnotic drugs in elderly patients.

High

Meperidine (Demerol)

Not an effective oral analgesic in doses commonly used. May cause confusion and has many disadvantages compared with other narcotic drugs.

High

Ticlopidine (Ticlid)

Has been shown to be no better than aspirin in preventing clotting and may be considerably more toxic. Safer, more effective alternatives exist.

High

Ketorolac (Toradal)

Immediate and long-term use should be avoided in older persons, since a significant number have asymptomatic GI pathologic conditions.

High

Amphetamines and anorexic agents

Have potential for causing dependence, hypertension, angina, and myocardial infarction.

High

Long-term use at full dosage, longer half-life, non-COX-selective NSAIDs: naproxen (Naprosyn, Avaprox, Aleve), oxaprozin (Daypro), piroxicam (Feldene)

Have the potential to produce GI bleeding, renal failure, high blood pressure, and heart failure.

High

Daily fluoxetine (Prozac)

Long half-life of drug and risk of producing excessive CNS stimulation, sleep disturbances, and increasing agitation. Safer alternatives exist.

High

Long-term use of stimulant laxatives: bisacodyl (Dulcolax), cascara sagrada, and Neoloid except in the presence of opiate analgesic use

May exacerbate bowel dysfunction.

High

Amiadarone (Cordarone)

Associated with QT interval problems and risk of provoking torsades de pointes. Lack of efficacy in older adults.

High

Orphenadrine (Norflex)

Causes more sedation and anticholinergic adverse effects than safer alternatives.

High

Guanethidine (Ismelin)

May cause orthostatic hypotension. Safer alternatives exist.

High

Guanadrel (Hyloral)

May cause orthostatic hypotension.

High

Cyclandelate (Cyclospasmol)

Lack of efffcacy.

Low

Isoxsurpine (Vasodilan)

Lack of efffcacy.

Low

Nitrofurantoin (Macrodantin)

Potential for renal impairment. Safer alternatives are available.

High

Doxazosin (Cardura)

Potential for hypotension, dry mouth, and urinary problems.

Low

Methyltestosterone (Android, Virilon, Testrad)

Potential for prostatic hypertrophy and cardiac problems.

High

Thioridazine (Mellaril)

Greater potential for CNS and extrapyramidal adverse effects

High

Mesoridazine (Serentile)

CNS and extrapyramidal adverse effects.

High

Short-acting nifedipine (Procardia, Adalat)

Potential for hypotension and constipation.

High

Clondinine (Catapres)

Potential tor orthostatic hypotension and CNS adverse effects.

Low

Mineral oil

Potential for aspiration and adverse effects. Safer alternatives are available.

High

Cimetidine (Tagamet)

CNS adverse effects including confusion.

Low

Ethacrynic acid (Edecrin)

Potential for hypertension and fluid imbalances. Safer alternatives are available.

Low

Desiccated thyroid

Concerns about cardiac effects. Safer alternatives are available.

High

Amphetamines (excluding methylphenedate hydrochloride and anorexics)

CNS stimulant adverse effects.

High

Oestrogens only (oral)

Evidence of the carcinogenic (breast and endometrial cancer) potential of these agents and lack of cardioprotective effect in older women.

Low

CNS, central nervous system; COX, cyclo-oxygenase; GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs; SIADH, syndrome of inappropriate antidiuretic hormone secretion.

Table 49.15 Criteria for potentially inappropriate medication use in older adults: considering diagnoses or conditions (Fick et al., 2003)

Disease or condition

Drug

Concern

Severity rating (high or low)

Heart failure

Disopyramide (Norpace), and high sodium content drugs (sodium and sodium salts (alginate bicarbonate, biphosphate, citrate, phosphate, salicylate, and sulphate))

Negative inotropic effect. Potential to promote fluid retention and exacerbation of heart failure.

High

Hypertension

Phenylpropanolamine hydrochloride (removed from the market in 2001), pseudoephedrine; diet pills, and amphetamines

May produce elevation of blood pressure secondary to sympathomimetic activity.

High

Gastric or duodenal ulcers

NSAIDs and aspirin (〉325 mg) (coxibs excluded)

May exacerbate existing ulcers or produce new/additional ulcers.

High

Seizures or epilepsy

Clozapine (Clozaril), chlorpromazine (Thorazine), thioridarine (Mellaril), thiothixene (Navane)

May lower seizure thresholds.

High

Blood clotting disorders or receiving anticoagulant therapy

Aspirin, NSAIDs, dipyridamole (Persantin), ticlopidine (Ticlid), clopidogrel (Plavix)

May prolong clotting time and elevate INR values or inhibit platelet aggregation, resulting in an increased potential for bleeding.

High

Bladder outflow obstruction

Anticholinergics and antihistamines, gastrointestinal antispasmodics, muscle relaxants, oxybutynin (Ditrapan), flavoxate (Urispas), anticholinergics, antidepressants, decongestants, tolterodine (Detrol)

May decrease urinary flow, leading to urinary retention.

High

Stress incontinence

α‎-Blockers (Doxazosin, Prazosin, Terazosin), anlicholinergics, tricylic antidepressants (imipramine hydrochloride, doxepin hydrochloride, amitriptyline hydrachloride), long-acting benzodiazepines

May produce polyuria and worsening of incontinence.

High

Arrhythmias

Tricyclic antidepressants (imipramine hydrochloride, doxepin hydrochloride, amitriptyline hydrochloride)

Concern due to proarrhythmic effects and ability to produce QT interval changes.

High

Insomnia

Decongestants, theophylline (Theodur), methylphenidate (Ritalin), MAOIs, and amphetamines

Concern due to CNS stimulant effects.

High

Parkinson’s disease

Metoclopramide (Reglan), conventional antipsychotics, tacrine (Cognex)

Concern due to their antidopaminergic/cholinergic effects.

High

Cognitive impairment

Barbiturates, anticholinergics antispasmodics, muscle relaxants. CNS stimulants: dextroamphetamine (Adderall), methylphenidate (Ritalin), methylphentamine (Desoxyn), pemolin

Concern due to CNS-altering effects.

High

Depression

Long-term benzodiazepine use. Sympatholytic agents: methyldopa (Aldomet), reserpine, guanethidine (Ismelin)

May produce or exacerbate depression.

High

Anorexia and malnutrition

CNS stimulants: dextroamphetamine (Adderall), methylphenidate (Ritalin), methamphetamine (Desoxyn), pemolin, fluoxetine (Prozac)

Concern due to appetite-suppressing effects.

High

Syncope or falls

Short- to intermediate-acting benzodiazepine and tricyclic antidepressants (imipramine hydrochloride, doxepin hydrochloride, amitriptyline hydrochloride)

May produce ataxia, impaired psychomotor function, syncope, and additional falls.

High

SIADH/hyponatraemia

SSRIs: fluoxetine (Prozac), citalopram (Celexa), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft)

May exacerbate or cause SIADH.

Low

Seizure disorder

Bupropion (Wellbutrin)

May lower seizure threshold.

High

Obesity

Olanzapine (Zyprexa)

May stimulate appetite and increase weight gain.

Low

COPD

Long-acting benzodiazepines: chlordiazepoxide (Librium), chlordiazepoxide-amitriptyline (Limbitrol), clidinium-chlordiazepoxide (Librax), diazepam (Valium), quazepam (Doral), halazepam (Paxiparn), chlorozepate (Tranxene). β‎-blockers: propranolol

CNS adverse effects. May induce respiratory depression. May exacerbate or cause respiratory depression.

High

Chronic constipation

Calcium channel blockers, anticholinergics, tricyclic antidepressant (imipramine hydrochloride, doxepin hydrochloride, amitriptyline hydrochloride)

May exacerbate constipation.

Low

CNS, central nervous system; COPD, chronic obstructive pulmonary disease; INR, international normalized ratio; MAOIs, monoamine oxidase inhibitors; NSAIDs, nonsteroidal anti-inflammatory drugs; SIADH, syndrome of inappropriate antidiuretic hormone secretion; SSRIs, selective serotonin reuptake inhibitors.

Clinical assessment, investigations, and screening for illicit drug use in older people

As with AUDs and IMU, a thorough history of any current or past use of illicit drugs should be recorded, along with mental state and physical examinations and collateral history, if available. Further investigations will be directed by the type of drug or drugs used, the route of administration, and the clinical findings.

The low levels of illicit drug use in current generations of older people mean that screening is unwarranted in most populations except for those with particularly high risk, such as the homeless and prison inmates, or people already known to have a history of AUDs and IMU.

Management and Prevention

Management and prevention can be broadly divided into primary prevention, secondary prevention, and tertiary prevention or treatment. Primary prevention refers to the prevention of problems arising for the first time (e.g. late-onset AUDs); secondary prevention aims to prevent the onset or worsening of problems in at-risk individuals (e.g. individuals with ‘heavy use’ of alcohol); and tertiary prevention refers to treatment for established problems (e.g. individuals with established alcohol dependence syndrome).

Moderate alcohol consumption and health

In considering the prevention of problems of alcohol misuse, it is important to be aware of the complex relationship between moderate alcohol consumption and health. Up to a hundred epidemiological studies conducted over the past three decades have demonstrated that, in relation to physical, social, psychiatric, and cognitive health and wellbeing, light–moderate drinkers seem to be generally healthier than both nondrinkers and heavy drinkers or those with AUDs, a phenomenon that has been referred to as the J- or U-shaped curve (Doll et al., 1994; O’Connell and Lawlor, 2005b). As a result, it has been argued that light–moderate consumption of alcohol, particularly red wine (the so-called French paradox), has beneficial effects on health. Furthermore, there is some empirical evidence linking light–moderate alcohol intake and an improved profile of cardiovascular biomarkers (Rimm et al., 1999).

However, there are a number of potential problems with the epidemiological evidence. Nondrinkers are a heterogenous group, comprised of both lifelong nondrinkers and individuals with a past history of AUD (so-called sick quitters), and the latter group may be less healthy than moderate drinkers for reasons other than their current drinking habits (Shaper, 1995). The ‘French paradox’, whereby moderate intake of red wine has been proposed as the factor responsible for the lower levels of cardiovascular disease in the French compared to British and American populations, has been questioned (Law and Wald, 1999). Moderate drinkers may also have other favourable physical (Shaper, 1995) and psychological health characteristics, such as differing personality type (O’Connell et al., 2005), in comparison to nondrinkers.

Furthermore, no controlled trials of light–moderate alcohol intake and effects on cardiovascular or other health characteristics have been performed and such trials are likely to encounter ethical barriers due to the neuropsychiatric effects of alcohol and the existence of proven treatments in the form of conventional medication.

Therefore, despite the epidemiological and biochemical evidence for potential health benefits of light–moderate alcohol intake, there is insufficient evidence at present to support advising moderate alcohol intake for the entire population, particularly when the many potential harmful effects of excessive alcohol intake are considered.

Management and prevention of AUDs

Primary prevention

Primary prevention aims to prevent the development of de novo AUDs in older people. Primary prevention of AUDs in older people is important, considering that up to 1 in 3 older people with AUDs may develop such problems for the first time in later life (Adams and Waskel, 1991). Clinicians should watch for the development of AUDs when an older person encounters stressful life circumstances and major changes or losses, particularly if that individual has a personal or family history of AUDs.

Primary prevention can also be seen as a strategy directed at the entire population, targeting factors such as ease of access to alcohol, alcohol pricing, restrictions on alcohol advertising, and education about the adverse effects of drinking. Such primary prevention and public health initiatives tend to be directed towards younger individuals, but they should also take into account the more clinically ‘silent’ AUDs that may develop in older people (O’Connell et al., 2003b).

Secondary prevention

Secondary prevention strategies should focus on older people who already have ‘at-risk’ drinking, either currently or in the past, and who are at risk of developing worsening problems in the context of diverse factors such as bereavement, social isolation, adjustment to retirement, and physical or psychiatric health problems. As with primary prevention, there should be a high index of clinical suspicion when assessing such people. There is emerging evidence that formalized brief psychological interventions in primary care may have a positive impact on AUDs in older people (Fleming et al., 1999; Blow and Barry, 2000). However, older people should also be referred on to specialist mental health and addiction services if problems persist.

Tertiary prevention

Tertiary prevention involves treatment of existing AUDs. Treatment modalities can be divided into biological/medical, social, and psychological. Biological/medical treatments are most important in the acute setting, where detoxification may be required. In view of increased physical frailty and evidence for more severe alcohol withdrawals in older people (Brower et al., 1994), it is advisable to admit older people requiring detoxification, preferably to a medical ward, particularly if there is a history of alcohol withdrawal seizures or delirium tremens. Fluid and electrolyte imbalances should be corrected and cognitive state should be monitored regularly in view of the risk of developing delirium.

Care should be taken with benzodiazepine-assisted withdrawal in older people, in view of the elevated risk of oversedation, confusion, and falls. There are no older-specific guidelines on benzodiazepine-assisted alcohol withdrawal. However, it has been established that older people have more severe alcohol withdrawals and receive higher doses of chlordiazepoxide as a result (Liskow et al., 1989). Lorazepam has been identified as the safest choice of benzodiazepine for treatment of alcohol withdrawal in older people, in view of the fact that advancing age and liver disease have little impact on its metabolism, and absorption by the intramuscular route is predictable (Peppers, 1996). Use of an objective measure of alcohol withdrawal, such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised Version (CIWA-Ar), is advisable in defining the severity of alcohol withdrawal and monitoring clinical course, although this scale is not older-specific and areas such as ‘orientation and clouding of sensorium’ may be disproportionately affected in older people, especially if cognitive impairment is present (Naranjo and Sellers, 1986) (Table 49.16).

Table 49.16 The Clinical Institute Withdrawal Assessment for Alcohol-Revised Version (CIWA-Ar)

Items 1–9 are scored from 0–7 and item 10 from 0–4. Maximum possible score is 67.

  1. 1. Nausea and vomiting

  2. 2. Tremor

  3. 3. Paroxysmal sweats

  4. 4. Anxiety

  5. 5. Agitation

  6. 6. Tactile disturbances

  7. 7. Auditory disturbances

  8. 8. Visual disturbances

  9. 9. Headaches and fullness in head

  10. 10. Orientation and clouding of sensorium

Severity of alcohol withdrawal

Mild: 10

Moderate: 10–20

Severe: 20+

Parenteral or oral thiamine should be given to prevent development of the Wernicke–Korsakoff syndrome. A recent review has concluded that, in the emergency department setting, oral thiamine administration is as effective as parenteral administration (Jackson and Teece, 2004). However, there are no older-specific guidelines, and individual patient characteristics must be taken into account, such as general health, ability to take oral medication, and compliance.

There is limited evidence available on the use of abstinence medications such as Disulfiram, Naltrexone, and Acamprosate in older people, and they are probably best avoided in view of the elevated risk of adverse effects. However, there is some evidence that Naltrexone may be safe and effective in treating AUDs in older people (Oslin et al., 1997a, 1997b).

Social aspects of treatment include identifying and addressing problems in such diverse areas as personal finances, housing, employment, and levels of social contacts, as continuing problems in these areas may serve to perpetuate the AUD. Psychological treatments include specific psychotherapies focusing on AUDs (e.g. motivational interviewing, addiction counselling) and psychotherapies aimed at comorbid mood or other psychiatric disorders. While there is little evidence on the effectiveness of psychotherapeutic approaches to addiction in older people, one review has concluded that only those studies involving behavioural and cognitive-behavioural interventions have provided empirical support for treatment effectiveness (Schonfeld and Dupree, 1995). There is also some evidence that older people may respond better to psychotherapy in same-age settings, i.e. among other older people (Kofoed et al., 1987; Schonfeld and Dupree, 1995), presumably because of a shared experience of the older-specific aspects of AUDs.

The wide variety of older-specific aspects of AUDs, along with a projected increase in the numbers of older people with AUDs in future years, and evidence for improved treatment response in same-age settings mean that the development of screening programmes and treatment facilities geared towards older people, which may be based on population-defined sectors, is now needed. Such screening and treatment programmes should involve collaboration between old age psychiatry and geriatric medicine and a multidisciplinary team should deliver treatment, targeting the many medical, social, and psychological aspects of AUDs in older people.

Management and prevention of IMU

Primary prevention

Along with patients themselves, healthcare workers, family members, and carers all have important roles in the primary and secondary prevention of IMU in older people. Prescriptions should be reviewed regularly with a view to simplification and rationalization if possible, and the practice of giving ‘repeat prescriptions’ without clinical assessment should be discouraged. Physicians should be aware of the potential for prescription drug abuse among older patients, particularly for opiate abuse and dependence, which has been steadily rising in the older age group, and should consider these problems when evaluating an older person.

Community pharmacists should have an active role in advising on the appropriate use of prescription and OTC medications, in cautioning patients on inappropriate use and on interactions with alcohol and other medications, and in alerting the prescribing physician when abuse, overuse, underuse, or inappropriate use of medication (either iatrogenically or due to patient behaviour) is suspected. Older patients should be advised at all times on the use of the appropriate dose of medication and on the dangers of escalating the dose without medical supervision, particularly benzodiazepines and opiates.

Patients should be educated about all aspects of their medication, including physical descriptions of the medication, the clinical indications, dose, and frequency and common side effects. If patients are unable to manage administration of their own medication due to cognitive or other impairments, provision should be made for a family member or caregiver to arrange this.

Several physical and cognitive impairments impact on the ability of an older person to open medicine containers. One study of older people aged 81 years and older, living in the community and in institutions in Sweden (Beckman et al., 2005), found that 14% were unable to open a screw-cap bottle, 32% a bottle with a snap lid, and 10% a blister pack. Less than half of those who were unable to open one or more of the containers received help with their medication, and only 27% of those living in their own homes received help.

Dosette boxes may be useful, but it has been pointed out that those patients most in need of them are the least likely to be able to manage them, and problems may occur with both filling the devices and the taking of medications from them (Levings et al., 1999). One study found that the use of a combination pack for medication used to treat osteoporosis was associated with improved understanding of medication directions and improved patient satisfaction (Ringe et al., 2006). A more recent study (Zedler et al., 2011) suggests that calendar packaging of medication through use of calendar blister packaging (CBP) and calendar pill organizers (CPO), especially in combination with education and reminder strategies, may improve medication adherence.

Active management of physical and psychiatric conditions also helps in primary prevention of IMU. For example, adequate treatment of depression and anxiety should lead to a reduced risk of benzodiazepine overuse, and adequate management of pain should lead to a reduced risk of overuse or abuse of opiates and other analgesics. Criteria such as those of Beers (Beers, 1997; Fick et al., 2003; Tables 49.14 and 49.15) should be taken into account when considering the most appropriate medication to prescribe, and the ones best avoided, for a particular condition in an older person.

Secondary prevention

Secondary prevention of IMU in older people should focus on those with a past history of IMU, and the medical conditions and medications listed among Beers’ criteria in Tables 49.14 and 49.15.

Tertiary prevention

Tertiary prevention of IMU in older people will depend on the medication in question and the clinical and sociodemographic profile of the patient. Admission to a medical or psychiatric ward may be required to facilitate reduction or stopping of certain medications, e.g. benzodiazepine and opiate detoxification, as outpatient detoxification in older people may be hazardous.

Management and prevention of illicit drug use

The relative rarity of illicit drug use in older people means that there is a dearth of information and guidelines on primary and secondary prevention. However, it is predicted that by 2020, the number of people over the age of 50 needing substance abuse treatment will double (Han et al., 2009). The ageing ‘baby-boomer’ generation in the US has been cited as a potential source of older illegal drug users (Patterson and Jeste, 1999) and so clinical experience in this area and the need for primary prevention strategies focused on both the individual and older people in general will need to expand in the future.

Secondary prevention strategies are likely to focus on those with a past history of illegal drug use, medical (e.g. pain) and psychiatric (e.g. AUDs) disorders that may increase the risk for illegal drug use, and social and environmental factors.

Tertiary prevention or treatment will depend on the drug in question and the clinical and sociodemographic characteristics of the patient.

Prognosis

Prognosis in AUDs

The available literature on the topic suggests that older people are at least as likely, if not more likely, to benefit from treatment of AUDs as younger people (Curtis et al., 1989; Oslin et al., 2002). However, prognosis in older people is likely to vary widely depending on a number of factors relating to individuals themselves and the nature of their AUD, the presence of family and other support systems, and the availability of treatment services, particularly services that are tailored to older people. Individuals with late-onset AUDs are generally felt to have a better prognosis than those with early-onset or life-long AUDs (Babor et al., 1992). Better prognosis may be related to the shorter history and milder severity of AUDs in this group, more intact social supports, higher income levels, and the presence of potentially modifiable precipitants such as depression, bereavement reactions, and social isolation. In contrast, the older individual with an early-onset or life-long AUD may have accumulated significant physical, psychiatric, cognitive, and social deficits that are more difficult to address. The higher prevalence of antisocial personality disorder and the higher risk of comorbid substance use in this group may also lead to increased difficulties in engagement with therapy.

Of particular relevance to the prognosis of AUDs in older people is the role of cognitive impairment, which is likely to act as a barrier to engaging with treatment. However, one study comparing cognitively impaired and cognitively intact outpatients enrolled in an intensive treatment programme found no significant intergroup differences in outcome; a wide range of treatment gains were seen in both groups, albeit with a higher level of treatment drop-out in the impaired group (Teichner et al., 2002).

The level of cognitive impairment is likely to be higher in the early-onset AUD group, but clinical experience suggests that there may be a subgroup of individuals with late-onset AUDs whose AUD arises as a result of cognitive impairment, with an increase in alcohol intake a behavioural manifestation of an early dementing process.

Comorbid psychiatric illness, gender (with possibly poorer prognosis in men), levels of social supports, and the availability of alternative and healthier social outlets (which may in turn be related to factors such as culture and ethnicity) may influence motivation for individuals to change their drinking habits.

In view of the wide range of older-specific aspects of AUDs, it makes intuitive sense that older people would be best treated by specialists in same-age settings, among other older people who may share similar problems, and there is evidence to suggest that such an approach is associated with a better outcome (Kofoed et al., 1987). However, despite the mounting evidence for the extent of AUDs in older people, older-specific treatment settings are few in number. Furthermore, engaging with such services may be dependent on an intuitive and motivated physician with sufficient training and expertise to identify the AUD and treat or refer appropriately.

Prognosis in IMU

Similar prognostic indicators that apply to AUDs are likely to be relevant to IMU, and centre on the individual’s clinical and sociodemographic characteristics, levels of support, and available services. The duration of inappropriate use and abuse and the medication or medications in question are also of relevance. For example, an older person who has been overusing benzodiazepines for decades is more likely to encounter adverse effects and difficulties with cessation than someone who has been overusing mild analgesics because of a recent worsening of arthritic pain. As with AUDs, the relationship with the individual’s physician, and the ability of the physician to identify and treat or refer appropriately, is vital. Likewise, motivation to address the IMU may be related to the individual’s mental health, level of cognition, and social circumstances.

Prognosis in illicit substance use

There is a dearth of literature in this area, but similar general principles of good and poor prognostic indicators that relate to AUDs and IMU are likely to apply to the use of illegal substances.

Smoking in Older People

Although use of tobacco (primarily through cigarette smoking) may be classified as a mental and behavioural disorder due to psychoactive substance use and may fulfil criteria for harmful use, dependence, and withdrawal states (Tables 49.2–49.6), and despite the fact that nicotine use is arguably associated with more morbidity and mortality in older people than alcohol and all other substance use disorders (Atkinson, 2001), this particular problem receives relatively little attention in the psychiatric literature. This is perhaps due to the fact that the neuropsychiatric effects of smoking are subtle and are not generally clinically significant, and there may be a perception that smoking palliates psychological distress. Indeed, a complex and circular relationship between depression, smoking, and medical illness has been described (Wilhelm et al., 2004).

We know that significant proportions of older people (approximately 10%) smoke (Bratzler et al., 2002), and this figure is likely to be higher again for older people with psychiatric disorders such as depression (Covey et al., 1998). The health impact of smoking is well documented elsewhere and includes malignancies (lung, oesophageal, bladder, etc.), cardiovascular disease (ischaemic heart disease, cerebrovascular disease, peripheral vascular disease, etc.), respiratory disease (chronic obstructive airway disease), and countless other problems. Furthermore, the effects of smoking are cumulative and age-related and it has been estimated that 70% of the excess mortality attributed to smoking in the US occurs in those over the age of 60 (Burns, 2000).

The key message from recent research on smoking in older people is that smoking cessation is possible in this age group and is worthy of active consideration in the individual clinical setting and in a wider public health context, in view of the considerable health benefits that are likely to accrue. LaCroix and Omenn (1992) found that older smokers who quit have a reduced risk of death compared with current smokers within 1–2 years of quitting, and overall risk of death approaches that of those who never smoked after 15–20 years of abstinence. Although the benefits of smoking cessation for longevity are most pronounced in younger people, a large study of smoking cessation has demonstrated that men over the age of 65 gained 1.4–2.0 years of life and women gained 2.7–3.7 years (Taylor et al., 2002).

Systematic reviews on the Cochrane database have demonstrated that nicotine replacement therapy through any mode (e.g. gum, spray, or transdermal patch) increases quit rates by 1.5- to two-fold regardless of setting (Silagy et al., 2002). Another such systematic review has demonstrated that the antidepressants bupropion and nortriptyline aid long-term smoking cessation, but the serotonin selective reuptake inhibitors (SSRIs) do not (Hughes et al., 2004). There is a dearth of research on such pharmacological approaches to smoking cessation specifically in older populations, and it must be borne in mind that any such therapies may be associated with higher levels of adverse effects in older people. In any comprehensive approach to improving the health of older people, however, consideration should be given to pharmacological therapies, along with advice and education on the many health benefits of smoking cessation.

Conclusion

This chapter has highlighted the importance of AUDs, IMU, and use of illicit drugs in older people, in terms of their prevalence and their important contribution to morbidity and mortality. AUDs are underdetected, misdiagnosed, and often completely missed in older populations. However, despite ageist and therapeutically pessimistic assumptions, AUDs in older people are as amenable to treatment as in younger people, and treating an AUD in individuals of any age can lead to significant benefits in their quality of life. Likewise, the wide variety of IMU in older people may be associated with addiction to medication and the undertreatment and inappropriate treatment of medical and psychiatric conditions. Considering that older people are the highest consumers of prescription medications, screening and treatment programmes for IMU should also lead to considerable improvements in quality of life, along with financial and other savings. Misuse of illicit drugs by older people is not generally a major problem at present, but it is virtually certain that consumption of illegal substances by people over 65 will increase in the future.

Greater awareness amongst physicians and other healthcare providers of the possibility of AUDs and IMU in their older patients should lead to the development of more comprehensive and age-appropriate prevention and treatment strategies. At the levels of everyday clinical practice and public health policy, greater emphasis should be placed on AUDs and IMU in older people, and further development and evaluation of dedicated ‘same-age’ treatment services and settings should be performed.

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