Substance Use and Older People

Substance use and addiction is an increasing problem amongst older people. The identification of this problem is often more difficult in older patients and is frequently missed, particularly in the primary care context and in emergency departments, but also in a range of medical and psychiatric specialties.

Substance Use and Older People shows how to recognise and treat substance problems in older patients. However, it goes well beyond assessment and diagnosis by incorporating up-to-date evidence on the management of those older people who are presenting with chronic complex disorders, which result from the problematic use of alcohol, inappropriate prescribed or over the counter medications, tobacco, or other drugs. It also examines a variety of biological and psychosocial approaches to the understanding of these issues in the older population and offers recommendations for policy.

Substance Use and Older People is a valuable resource for geriatricians, old age psychiatrists, addiction psychiatrists, primary care physicians, and gerontologists as well as policy makers, researchers, and educators. It is also relevant for residents and fellows training in geriatrics or geri-psychiatry, general practitioners and nursing home physicians.

Ilana Crome, Emeritus Professor of Addiction Psychiatry, Keele University, Keele, UK; Honorary Consultant Psychiatrist, South Staffordshire and Shropshire Healthcare NHS Foundation Trust, Stafford, UK; Honorary Professor, Queen Mary University of London, London, UK; Senior Research Fellow, Imperial College, London, UK

Li-Tzy Wu, Professor of Psychiatry, Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA

Rahul (Tony) Rao, Visiting Researcher, Department of Old Age Psychiatry, Institute of Psychiatry, London, UK and Lead for Dual Diagnosis, Mental Health of Older Adults and Dementia Clinical Academic Group, South London and Maudsley NHS Foundation Trust, UK

Peter Crome, Honorary Professor, Department of Primary Care and Population Health, University College London, London, UK; Emeritus Professor of Geriatric Medicine, Keele University, Keele, UK

Contributors xvii

Foreword xxi

Introduction xxiv

List of Abbreviations xxvi

Section 1 Legal and ethical aspects of care for older people with substance misuse 1

1 Negotiating capacity and consent in substance misuse 3
Kritika Samsi

Introduction 3

Substance abuse and capacity 3

Mental capacity legislation 4

Mental Capacity Act 2005 4

Capacity assessment 5

Capacity and unwise decisions 6

Consent, barriers to decision making and substituted decision making 6

Best interest decisions 8

Independent decision makers 8

Conclusion 9

References 9

2 Elder abuse 11
Jill Manthorpe

Introduction 11

Defining elder abuse 11

Main reviews 12

Alcohol and substance misuse risk factors 12

Risk factors among older people 13

The effects of elder abuse 14

Discussion 15

Conclusions and next steps 15

References 16

3 The United States perspective 18
Cynthia M.A. Geppert and Peter J. Taylor

The ageing of the baby boomers and its impact on substance abuse 18

Ethical and legal aspects of substance misuse in older adults 19

Confidentiality 19

Informed consent 20

Capacity 21

Coercion 24

Conclusion 25

References 25

4 The European perspective 27
Abdi Sanati and Mohammed Abou-Saleh

Introduction 27

Use and possession 28

Crime 28

European Convention of Human Rights 28

Delivering services for the elderly with substance misuse – ethical aspects 29

Research and development 30

Policy making 31

Some differences between Europe and the USA 31

Ethical issues regarding treatment 32

Stigma 32

Underprescribing controlled drugs 32

Summary 33

References 34

5 Clinical medicine and substance misuse: research, assessments and treatment 35
Amit Arora, Andrew O’Neill, Peter Crome and Finbarr C. Martin

Introduction 35

Why is clinical medicine important? 36

Identification 37

The health effects of substance abuse 39

Challenges for the future 46

Research 47

Identification tools 47

Training and support 48

Conclusions 49

References 49

Section 2 Epidemiology and demography 57

6 Cigarette smoking among adults aged 45 and older in the United States, 2002–2011 59
Shanta R. Dube and Li-Tzy Wu

Introduction 59

Evaluation methodology 61

Results 62

Sociodemographic characteristics of older adults: 2002 versus 2011 62

National trend in current smoking prevalence: 2002–2011 65

Current smoking prevalence by socioeconomic status: 2002 versus 2011 66

Adjusted odds ratios of correlates of current smoking: 2002 versus 2011 66

Discussion 71

Conclusion 72

References 73

7 Epidemiology and demography of alcohol and the older person 75
Stephan Arndt and Susan K. Schultz

Introduction 75

Main reviews 76

Epidemiological estimates of prevalence of alcohol use 76

Estimates of alcohol problems based on amount of drinking 76

Importance of threshold selection for defining problem use 80

Estimating problem use from survey samples 80

Summary of epidemiological estimates 81

Specific problematic drinking behaviours: binge drinking 81

Diagnoses of abuse or dependence 83

Older substance abuse treatment populations 84

Special populations of older substance users 85

Demographic correlates of problem use 86

Discussion 87

Conclusions and next steps 87

References 88

8 Epidemiology and demography of illicit drug use and drug use disorders among adults aged 50 and older 91
Shawna L. Carroll Chapman and Li-Tzy Wu

Introduction 91

Survey studies 92

Studies of treatment-seeking or clinical patients 101

Health implications 104

Discussion 105

Next steps 106

References 106

9 Epidemiology and demography of nonmedical prescription drug use 109
Jane Carlisle Maxwell

Introduction 109

Findings 110

National surveys 110

Emergency department cases 112

Treatment admissions 113

Drug poisoning deaths 114

Discussion 116

Conclusions 118

Acknowledgement 118

References 118

Section 3 Longitudinal studies of ageing and substance abuse 121

10 Ageing and the development of alcohol use and misuse 123
Marja Aartsen

Background 123

Results 124

Differences in alcohol use across cohorts 125

Developments in alcohol use within people 126

Gender differences 126

Different trajectories 126

Age and onset of problem drinking 127

Discussion 127

Explanations for age differences in alcohol use 127

Conclusions 128

References 129

11 Progression from substance use to the development of substance use disorders 133
Carla L. Storr and Kerry M. Green

Introduction 133

Substance use progression process 134

Risk factors influencing substance use progression 137

Individual factors 137

Substance properties 139

Environmental influences 140

Future direction 141

Conclusions 143

Acknowledgement 144

References 144

12 Psychopharmacology and the consequences of alcohol and drug interactions 149
Vijay A. Ramchandani, Patricia W. Slattum, Ashwin A. Patkar, Li-Tzy Wu, Jonathan C. Lee, Maitreyee Mohanty, Marion Coe and Ting-Kai Li

The extent of alcohol and drug misuse among older adults 149

Substance misuse in the general population 149

Substance misuse or addiction in clinical settings 150

Co-morbidities among older substance misusers 151

Psychopharmacology of alcohol and drug misuse in older people 152

Neurocircuitry of abused substances 152

Alcohol–drug interactions in older adults 155

Mechanisms of alcohol–medication interactions 156

Significance of the problem 156

Concurrent use of alcohol and potentially interacting medications 157

Consequences of concurrent use of alcohol and medications 158

Clinical presentation and evaluation of substance use disorders in the elderly 158

Clinical presentations (case vignettes) 159

Medical co-morbidities 161

Screening for substance use disorders 161

Evaluation of substance use disorders 162

Cognitive impairment in the elderly with substance use disorders 163

Safety assessment of the elderly with substance use disorders 164

Medications for individuals with substance use disorders 164

Conclusions 166

References 166

Section 4 Comprehensive geriatric assessment and special needs of older people 171

13 Comprehensive geriatric assessment and the special needs of older people 173
Dan Wilson, Stephen Jackson, Ilana B. Crome, Rahul (Tony) Rao and Peter Crome

Background 173

Assessment 175

Setting 176

Barriers to assessment 176

High-risk groups 177

Presenting problems 177

Collateral information 178

General principles of assessment 179

Screening 182

Psychiatric assessment 183

Case presentations 184

Driving and substance misuse 184

Older women and alcohol misuse 184

Polysubstance misuse 185

The frequent attender 185

Alcohol and cognitive impairment 186

Pain and substance misuse 187

Discussion 187

Conclusion 187

References 188

Section 5 Screening and intervention in health care settings 193

14 Screening and brief intervention in the psychiatric setting 195
M. Shafi Siddiqui and Michael Fleming

Overview 195

Screening and assessment for alcohol use disorders 197

Single question screen for an alcohol use disorder 197

Quantity and frequency questions 198

Proxy questions such as CAGE 198

Symptoms of abuse or dependence 199

Alcohol biomarkers 199

Illicit drugs 202

Rationale for screening older adults for marijuana, cocaine and other illicit drugs 202

Screening for illegal drugs in the psychiatric setting 202

Recommended screening questions to detect drug use 202

Screening for drug abuse/dependence 203

Screening for illicit drug use with toxicology screening 203

Prescription drug abuse 204

Rationale for screening older adults 204

Screening for prescription drug abuse 205

Brief intervention for alcohol, prescription drug abuse and illegal drug use 206

Summary 208

References 209

15 Tobacco use cessation 212
Daniel J. Pilowsky and Li-Tzy Wu

Introduction 212

Smoking cessation interventions among older adults 214

Multimodal interventions 214

Medication-based interventions 216

Counselling and behavioural interventions 217

Physician-delivered interventions 217

Other interventions 218

Conclusions 218

References 219

Section 6 Use of substance abuse treatment services among older adults 223

16 Epidemiology of use of treatment services for substance use problems 225
Shawna L. Carroll Chapman and Li-Tzy Wu

Introduction 225

Tobacco cessation service use and characteristics 225

Alcohol treatment use and characteristics 230

Trend in substance abuse treatment admissions 238

Drug abuse treatment use and outcomes 243

Substance abuse treatment in general health care settings 245

Discussion and conclusion 246

References 247

17 Implications for primary care 249
Devoshree Chatterjee and Steve Iliffe

Background 249

Implications for primary care 249

Different populations at risk 250

Screening in primary care 251

Scale of benefit 252

Co-morbidities and social context 252

Conclusions 253

References 253

18 Addiction liaison services 255
Roger Bloor and Derrett Watts

Introduction 255

Organizing an addiction liaison service to a general hospital 256

Case vignette 1 256

Addiction liaison services for older adults 257

Essential elements of liaison service provision for older adults 258

Screening for alcohol problems in older adults 259

Screening for drug use problems 260

Case vignette 2 260

Summary 261

References 262

19 Current healthcare models and clinical practices 265
Rahul (Tony) Rao, Ilana B. Crome, Peter Crome and Finbarr C. Martin

Introduction 265

An ageing population 265

Service development and provision 266

Integrated care and workforce development 267

Conclusions and recommendations 269

References 269

Section 7 Age-specific treatment interventions and outcomes 271

20 Pharmacological and integrated treatments in older adults with substance use disorders 273
Paolo Mannelli, Li-Tzy Wu and Kathleen T. Brady

Introduction 273

Tobacco 274

Alcohol 275

Opioids 277

Benzodiazepines 278

Other substances of abuse 280

Stimulants 280

Cannabis 281

Integrated treatments 281

Conclusion and future directions 284

References 285

21 The assessment and prevention of potentially inappropriate prescribing 295
Denis O’Mahony

Introduction 295

Inappropriate psychotropic use in elderly patients 296

Implicit IP criteria 297

Explicit IP criteria 298

Applying STOPP/START criteria as an intervention 299

Other methods of detection and prevention of IP in older people 307

Comprehensive Geriatric Assessment (CGA) 307

Pharmacist review and intervention 308

Prescriber education, audit and feedback 308

Computerized provider order entry with clinical decision support 309

Conclusions 309

References 310

22 Age-sensitive psychosocial treatment for older adults with substance abuse 314
Kathleen Schutte, Sonne Lemke, Rudolf H. Moos and Penny L. Brennan

Introduction 314

Seven characteristics of age-sensitive treatment 316

1 – Supportive and nonconfrontational 316

2 – Flexible 316

3 – Sensitive to gender differences 317

4 – Sensitive to cultural differences 317

5 – Focus on client functioning 318

6 – Holistic 319

7 – Focus on coping and social skills 319

Six components of age-sensitive psychosocial treatment 320

1 – Biopsychosocial assessment 320

2 – Treatment planning 321

3 – Attention to co-occurring conditions 322

4 – Referrals and care coordination 325

5 – Empirically-supported psychosocial interventions 325

6 – Adjuncts to psychosocial interventions 328

Age-segregated or mixed-age treatment 329

Future directions 330

Acknowledgements 331

References 332

23 Integrated treatment models for co-morbid disorders 340
Rahul (Tony) Rao

Introduction 340

Methodological approach to examining SMCD in older people 341

A. Current systems of care for substance misuse and mental disorders 341

B. Service implications 342

C. Principles underlying integrated treatment models for SMCD in older people 342

D. Developing integrated treatment models for older people with substance misuse and co-morbid psychiatric disorders 344

E. Research evidence for integrated treatment models 346

Future direction and challenges 347

References 347

Section 8 Policy: proposals for development 351

24 Proposals for policy development: drugs 353
Susanne MacGregor

Introduction 353

Recognition of a need or problem and arguments made to justify the development of policy 354

Policy options 356

Policy design and implementation 359

Conclusion 360

References 360

25 Proposals for alcohol-related policy development United States 364
Ralph Hingson and Ting-Kai Li

Recommended low-risk alcohol consumption levels 364

Traffic crash risks among the elderly 365

Driving policy questions 365

Factors to consider when contemplating legal policies 365

Summary and conclusions 369

References 370

26 Proposals for policy development: tobacco 372
Michael Givel

Introduction 372

Past and present approaches to reduce tobacco consumption 372

Phase three anti-tobacco efforts 373

Legal approach 373

Regulatory and tobacco tax approaches 374

Anti-tobacco counter-marketing campaigns 376

Recent anti-tobacco proposals 376

Product modification and ‘safer’ cigarettes 376

Harm reduction 377

Cigarette neo-prohibitionism 377

Smoke-free movies 377

Policy proposals to further reduce tobacco prevalence 378

References 378

27 Recommendations 383
Ilana B. Crome, Peter Crome, Rahul (Tony) Rao and Li-Tzy Wu

Background 383

Epidemiology 384

Clinical presentations 384

Education and training 385

Who gets treatment – treatment interventions 386

Concluding remarks 386

Index 388

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