Introduction
It is now well established that not only is the number of older people in our communities increasing, but also that their use of alcohol and prescription drugs is rising. North American studies indicate that the substance problem for which elders most often seek treatment is alcohol, but only 6-7% of high risk drinkers over 60 years old are receiving the treatment that they require. Older drinkers are less likely to declare that they have a problem, more likely to have low dependence on alcohol, less likely to demonstrate hostility, and more likely to be motivated to abstain.
The treatment system is unprepared partly because we are dealing with an invisible epidemic. This is due to numerous factors e.g. ageism, denial, stereotypes, non-specific symptoms, complex multiple diagnoses in addition to stigma, shame and isolation which older substance users experience. However, since older people are more likely to be in contact with the healthcare system there is significant potential to identify problems associated with alcohol misuse.
When we want to consider the benefit of treatment, we need to understand who comes for treatment, why they come for treatment, where treatment takes place, the healthcare model in which treatment takes place, what specific treatment is administered, and the outcome of treatment.
Psychosocial treatment
Though more research needs to be done, the key message is that older people should not be barred from treatment because of age. Consistently positive findings have emerged from studies on psychosocial treatment for substance problems in the older patient. The studies demonstrated that older people want to abstain; have the capacity to change; can be successfully offered help by physicians; respond are well to brief advice and motivational enhancement therapy; can be treated outside an age specific programme; can achieve improvement in outcomes across the range of domains (mental and physical health, relationships, legal, occupational and financial issues) comparable to younger adult populations; and have the prospect of long term recovery.
Two recent studies (BRITE: Brief intervention and treatment for elders and HLAYA: Healthy living as you age) in addition to those undertaken previously i.e. GOAL (Guiding older adult lifestyles) and PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly) further elucidate the value of intervention. For example, BRITE reported a reduction of alcohol use and problems from 80% to 18% though it is difficult to draw conclusions due to the variability of the interventions and because it was not controlled. The HYALA study demonstrated that there was improvement in both the controlled condition (advice) and intervention (integrated care) groups at 12 months. This is in keeping with the PRISM-E study which found that patients did better in integrated mental health and substance misuse care in primary care compared with referral to providers.
Pharmacotherapy
Medications should be cautiously administered in older people by experts experienced in the fields of addiction and geriatric medicine and monitored assiduously. There are a few small pharmacological studies on older alcohol misusers, and those that have been undertaken indicate that drugs such as acamprosate, disulfiram and naltrexone are effective, safe and well tolerated. Any pharmacological intervention should be in the context of psychosocial treatments.
Age sensitive treatment
Since there is no single empirically supported psychosocial intervention that is superior, clinicians need to be responsive to the needs of older people and to support adaptive coping strategies. Techniques which likely to yield benefit include brief interventions, motivational interviewing, motivational enhancement and cognitive behavioural therapy.
The components of age sensitive treatment include a biopsychosocial assessment, treatment plans and goals, and regular re-assessment. Comorbid issues such as pain, cognitive impairment, and depression are some of the most common co-occurring conditions which influence treatment outcome so protocols for referral to addiction and geriatric services are fundamental to care coordination of psychosocial and pharmacological interventions.
Staff need to be well trained, to enjoy working with older people, to be flexible to change with the fluctuating needs of their clients, as well as being cognisant of the appropriate goals, approaches, location, mode and duration of treatment for older people. Other problems which may affect older people need to be given due recognition e.g. accommodation, finance, physical illness, cultural differences, transport and accessibility. Patients may need to work at a slower pace, with shorter treatment sessions, and with the opportunity for reviewing and summarising information in a written format. Other components may include mutual self-help, age segregated treatment, care coordination and the use of information technology which may be less stigmatising.
Conclusion
Old age should not be a barrier to treatment. Older people can be offered treatments that are of proven effectiveness in the adult population, but monitored by a multidisciplinary team including specific expertise in addiction and ageing, and adapted to the needs of older people. All substance use should be considered: alcohol, tobacco, polypharmacy, illicit drugs, over the counter medication and misuse of prescription drugs. Associated mental health and physical health difficulties need to be viewed in light of the combination of substances and interactions with clinical conditions.
In the future, older people need to be enrolled in trials of pharmacological agents and psychosocial interventions. Combinations of treatments need further study so that findings can inform improved decision making or the mechanism of action. Longer term study may lead to recommendations for the utilization of specific interventions and the development of appropriate treatment programmes so that service models can evolve collaboratively with a choice of input.
Professor Ilana B Crome
KEY READING
Rao RT, Crome I, Crome P. et al. Substance misuse in older people: an information guide. Cross faculty report, older persons’ substance misuse working group. London: The Royal College of Psychiatrists, 2015. Available https://www.rcpsych.ac.uk/pdf/Substance%20misuse%20in%20Older%20People_an%20information%20guide.pdf
The Royal College of Psychiatrists (2018) Our Invisible Addicts.(2nd edition) Available https://www.rcpsych.ac.uk/usefulresources/publications/collegereports/cr/cr211.aspx
Crome I, LI TK, Rao R et al. (2012). Alcohol limits in older people. Addiction 107: 1541-1543
The opinions expressed in this commentary reflect the views of the author(s) and do not necessarily represent the opinions or official positions of the Society for the Study of Addiction.