Transcript Assessment of substance use in older people

Professor Ilana Crome
Keele University
21 March 2013
Thanks to colleagues and friends
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Prof Peter Crome
Dr Tony Rao
Dr Martin Frisher
Dr Roger Bloor
Dr Alex Baldacchino
Drs Ishbel Moy & Harvinder Sidhu, our
future!
And many other collaborators…
Professor Ilana Crome
Dr Karim Dar
Dr Stefan Janikiewicz
Dr Tony Rao
Dr Andrew Tarbuck
OVERVIEW
Why is it important
 What current research tells us
 How do we deal with it now
 The future
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Peter’s contributions
Peter’s Principles
Style - Non judgemental, non
confrontational
 Demystify and destigmatise
 What’s special and distinctive?
 Proactive and positive
 Evidence and uncertainties
 Chronic disease - resilience but
vulnerability
 Dignity, integrity, (e)quality and
compassion
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Substance misuse is:
WHY IS IT IMPORTANT?
WHY IS IT IMPORTANT?
Scale of the problem
 Burden of disease
 Lifespan issue
 Mortality
 Financial costs
 Societal impact
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CONTEXT
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Older people will constitute ~25% of the UK
population by 2020; currently 18% over 65s
Overall increase in older people using alcohol
and illicit substances over past decade
National surveys of alcohol, illicit drugs,
prescription drugs, presentations to Accident
and emergency units, presentations to
specialist services, hospital admissions
(poisoning, drug related mental disorders,
alcohol related physical disorders)
Prediction: set to double in the next 2 decades
How much do older people use?
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13% men,12% women over 60 still smoke
Smoking largest cause of premature death
45% NHS prescriptions for over 65s, twice
Alcohol consumption above adult ‘safe
limits’: 20% in men, 10% in women over 65
Highest alcohol death rate in aged 55-74
5% over 45s used any illicit drug over the
previous year, 0.7% used a Class A drug
Increasing over 40s coming into treatment
– 17% in drug treatment units are over 40
EUROPEAN DISEASE BURDEN ATTRIBUTABLE TO
SELECTED LEADING RISK FACTORS (2000)
Blood pressure
Tobacco
Alcohol
Cholesterol
High Body Mass Index
Fruit and vegetable intake
Physical inactivity
Illicit drugs
0
5000
10000
15000
20000
Number of Disability-Adjusted Life Years (000s)
Most difficult to give up
(among those who consume in previous year)
50
40
30
20
10
0
tobacco
alcohol
cannabis
heroin
ecstasy
LSD
NIGHT LIFE AND RECREATIVE DRUG USE IN EUROPE
A study in 10 European Cities 1998
Lifespan perspective
Early life difficulties – maltreatment,
distress – associated with substance
use disorder and psychiatric comorbidity
90% people who use substances
problematically have started before the
age of 19
Addiction can be a life long problem
Cannabis case
grandmother is
spared prison
Peter’s contribution NO LONGER
ONLY A YOUNG MAN’S DISEASE
ILLICIT DRUGS
May 2011
POISONING - ANTIDEPRESSANTS
May 2011
POISONING - PARACETAMOL
May 2011
PERSPICACITY
May 2011
SOURCE: British Beer and Pub Association 2008
Year
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
Alcohol Consumption in the UK in litres per head
Per capita alcohol consumption in the
UK, 1984-2008
9.5
9
8.5
8
7.5
7
Alcohol-related mortality per 100,000 in
the UK from 1984 – 2008 trebled
15
14
13
Mortality per 100,000
12
11
10
9
8
7
6
Year
SOURCE:
UK Office of National statistics, the Scottish Government and the Northern Ireland Department of Health.
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
4
1984
5
Harms and costs
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ALCOHOL - all time high  DRUGS
3rd leading cause of death  Increased for a decade
 £15 billion per annum
£21 billion per annum
 300,000 children
1 million children
 3% - £ 0.5 bn – NHS
£2.7 billion - health
~£7 billion crime-related  6% - £1bn - deaths
 90% is due to crime
£6.4 bn - workplace
Family, friends and wider communities - not
quantified – child protection, divorce,
homeless
COSTS – GREATER FOR OLDER
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More than 10 times -The cost of alcoholrelated inpatient admissions in England for 55
to 74 year olds was £825.6m compared to
£63.8m for 16 to 24 year olds in 2010/11.
8 times as many 55 to 74 year olds (454,317)
were admitted as inpatients compared to 16 to
24 year olds (54,682).
The cost of alcohol-related inpatient admission
was £1,993.57m, over 3 times greater than the
cost of A&E admissions, £636.30m.
The cost of alcohol-related inpatient
admissions for men was £1,278.4m, just under
double the cost for women, £715.1m.
PRICING AND POLICY
HARMS
Distinctive issues
Substance use decreases with age, but
can be more dangerous
 Older people are at increased risk of the
adverse physical effects as substances
accumulate due to decreased metabolism
 Brain sensitivity to drugs may be increased
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Women metabolise faster; more severe
effects earlier, present later; more
comorbidity
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May not have dependence eg withdrawal
Distinctive issues
INTERACTIONS AND MISTAKES
 Physical and mental health problems –
eg sleep, anxiety, pain - hypnotics,
anxiolytics and analgesics with abuse
potential
 Complexity, long term chronic disorders
 Self management in partnership –
embedded in preventative, communities
and team based, continuity, responsive,
flexible coordinated and integrated
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Precipitants and complications
Self harm a serious risk
 Psychiatric problems associated with
substance use eg intoxication,
withdrawal, dependence, anxiety,
depression, psychosis, cognitive
dysfunction
 Psychosocial factors eg bereavement
(spouse, friends, family), retirement,
boredom, loneliness, homelessness,
loss of income,
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Alcohol with symptoms
PETER HAS SEEN ALCOHOL
PROBLEMS IN MEMORY CLINIC
 Memory problems
22.5%
 Sleeping problems
38.5%
 Feeling sad or blue
16.8%
 Tripping, falling
17.8%
 Gastrointestinal
24.1%
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Physicians should notice alcohol
use complications
Hypertension
 Depression
 Gout
 Diabetes
 Ulcer disease
 Liver condition
 Pancreatitis
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30%
12%
7.6%
5.2%
4.1%
3.5%
0.6%
Alcohol with medications
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Antihypertensives
Ulcer medications
NSAID
Antiplatelet
Non-prescription
Antidepressants
Sedatives
Opioids
Nitrates
Warfarin
Seizure
31.7%
18.2%
17.9%
17.3%
12.7%
11.9%
10.1%
6.7%
4.3%
4.4%
0.6%
BARRIERS TO DETECTION – AND
HOW TO RESPOND
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Training – competence, screening tools
Stigma, moral weakness – non-judgmental,
non-confrontational
Under-reporting – comprehensive history
Mis-attribution of symptoms, underdiagnosis – awareness of subtle
presentations, high index of suspicion
Ageism – ‘that is all she has left’
Stereotyping – older, higher social class,
more educated, women
DETECTION - AWARENESS
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Altered/erratic behaviour or symptoms
Poor
response to treatment for
medical illness, request for
prescription drugs, sharing, storing
Past personal history/family history of
substance misuse & legacy of
personal, legal, occupational deficits
Illegal activities
THE 5 A’s
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ASK – all drugs, dependence,
ambivalence, non-judgemental
ASSESS – motivation, goals, complications
ADVISE – ‘brief intervention’ – feedback,
information, self help material
ASSIST – coping strategies, hope, self
esteem
ARRANGE – admission – severe addiction,
polysubstance, social, comorbidity, relapse
DAPA-PC Drug and Alcohol Problem
Assessment for Primary Care (Blazer)
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Computerized screening system quickly
identifies substance problems in primary
care
Can be used by psychiatrists as well
DAPA-PC is self administered, internet
based, automatic scoring
Generates patient profile for medical
reference
Presents unique motivational messages
and advice for the patient
Information technology
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Save clinicians’ time
Patients to be screened in the waiting room
Clinician to follow-up with a patient only when
prompted by the results of screen
Computerized screening may lend itself to a
more honest revelation regarding drug use
compared with face-to-face discussions.
Acceptability of computers by the elderly will
only increase.’
Peter has been interested in this for a long
time
CURRENT RESEARCH
WHAT DOES IT TELL US?
Alcohol dependence was last among 30 medical conditions in
proportion of care received as evidence would recommend
Senile cataract
Breast cancer
Prenatal care
Hypertension
Asthma
Diabetes Mellitus
Urinary Tract Infection
Atrial Fibrillation
Alcohol Dependence
78.7%
75.7%
73.0%
64.7%
53.5%
45.4%
40.7%
24.7%
10.5%
Source: McGlynn E., et al., (2003). The quality of health care delivered to adults in In the United
States. New England Journal of Medicine, 348.
Trials and guidelines
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Usually dictated by clinical trials
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Complex patients excluded ie
unrepresentative samples eg older,
substance users, comorbidity
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Combined treatments rarely studied
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Guidelines are not for older people
May 2011
May 2011
Peter’s first randomised clinical
trial!
May 2011
Pharmacological treatment
Medication
Licensed
Age limits
Specific old age
Diazepam
Alcohol
withdrawal
Not in children
<half adult dose
In anxiety
Chlordiazepoxide
Alcohol
withdrawal
Not in children
< half adult dose
for anxiety
Disulfiram
Alcohol deterrent
Not in children
None
Methadone
Opiate addiction
Not in children
Caution
Subutex
Opiate addiction
>16 years
None
Lofexidine
Opiate detox’n
Not in children
Caution
NRT
Nicotine
withdrawal
> 18 years
None
Bupropion
Smoking cessation > 18 years
Caution
Pharmacological treatments
Need to diagnose dependence
 Management of withdrawal symptoms
 Maintenance of abstinence eg methadone,
buprenorphine;nicotine replacement,
bupropion
 Prevention of complications
 Relapse prevention
 Psychiatric conditions eg depression
 Physical conditions eg diabetes
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Ishbel Moy
Martin Frisher
Peter Crome
Ilana Crome
Overview of Study Findings Myths dispelled
Value in treating older adults
Physicians can help
Brief Advice and Motivational Enhancement are
equally successful for both older and adult
population
Respond positively
Have the capacity to change
Number achieving follow-up goal is at least as good
as compared with younger adults
Effective treatment in elder-specific or adult
programme – could do even better
Overview of Study Findings
Good outcomes in substance use, mental and
physical health, and social function
Both older men and women are capable of achieving
abstinence if given access to alcohol abuse
programs
Should be encouraged to seek treatment for
substance dependence
Recovery prospects encouraging, long-term
management further research
Older age should not be a barrier to addressing
drinking problems - something Peter has done
Addiction Research Unit
 Comprehensive
assessment
 Single detailed
counselling session
 Follow up to check on
progress
 Basic treatment scheme
of 3 hours of
assessment and advice
is effective in reducing
alcohol problems in
moderately dependent
drinkers
Motivational interviewing/enhancement
 Non-confrontational
principles and style
 Increase effectiveness
of more extensive
psychosocial treatments
 Could be effective as
preparation for more
intensive treatments
 Potentially more cost
effective
COST EFFECTIVENESS
benefits –
saving of £5 for every
£1 invested
 Social benefits also
 Alcohol interventions
are highly cost
effective in
comparison with other
health care
interventions
 Economic
‘Safe’ limits
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No such thing as a safe limit
Adult safe limits may not apply
For some healthy older people, 1 US (14 gm
alcohol) drink a day, and no more than 7 a
week (UK unit = 8 gm IE 1.5 units daily)
More than 3 US drinks a day is harmful
Should not drink and drive, swim, use
machinery. Should eat before drinking
Drink more slowly ie over two hours
For those with comorbid conditions, on
medications, no alcohol may be appropriate
Under review by the Chief Medical Officer
Key Issues for Doctors
Prevention of disease of later life
 Prevention of functional decline
 Early identification of disease with rapid
response
 Supporting participation
 Application of evidence-based approaches
 Ageing, multiple pathology, vulnerability and
resilience
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Key Issues for Older People
Finance
 Housing
 Food
 Warmth
 Family
 Work
 Health
 Participation and functional status
 Cognitive decline
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TRAINING – ROLE MODEL, KNOWLEDGE,
SKILLS, ATTITUDES
May 2011
Training
Not an optional extra – improve attitudes,
reduce stigma, reverse therapeutic nihilism
 Royal Medical Colleges - Undergraduate,
specialist post graduate, continuing
professional development - competencies
 Multidisciplinary specialists - Old age
psychiatrists, geriatricians, addiction
specialists, nursing, psychology, social
care and other allied professionals
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The future – not only baby
boomers!
A UK based research programme on older
substance misusers
 Prescription drug use
 Any particular intervention, specific
programme, service model can be
recommended - over long term
 Policy implementation
 RCPsychiatrists Information Guide – Peter is
contributing
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A question of values? Dignity,
integrity, compassion and (e)quality
 Health
eg mental illness, cognitive
impairment
 Life circumstance eg poverty, in prison,
family conflict, social isolation
 Behaviour eg substance misuse, crime
 Status eg older, victim of abuse, refugee,
immigrant
 Personal quality eg low self esteem,
impaired functional life skills
19 March 2013 Guardian