Alcohol use disorders and acquired brain injury among older people who are homeless

1. Alcohol use disorders and acquired brain injury among older people who arehomeless Lucy Burns 1, Elizabeth Conroy2 Stephen Wilson 3 1 National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia 2. University of Western Sydney 3 Independent consultant Acknowledgment : Participants, Haymarket Centre, Foundation for Alcohol Research and Education

2. Structure • The context: Alcohol and drug use and ageing Australia • Alcohol use and homelessness • Alcohol use and brain injury • What does this mean for policy and practice?

3. Alcohol use and problems are not new…. "...alcohol has existed longer than all human memory. It has outlived generations, nations, epochs and ages. It is a part of us. For most of us it will continue to be the servant of man (and woman) but will always be the master of some." Morris Chaftez, Founding director, National Institute on Alcohol Abuse and Alcoholism.

4. What are the alcohol and drug use experiences of our older Australians? • End of WW2 in 1945 Australia's ex-service men and women returned to family life after 6 years of war conflict • Came back from war with legacy • Methamphetamine (Pervitin) to work, alcohol to wind down • Nine months after return from war childbirth rates soared – more than 4 million born 1946-51: “baby boomer generation”

5. 1950s and 1960s: Boomers teens and young adults • Widespread testing and use of new synthetic pharmaceuticals • LSD testing , wider use of new drugs in psychiatry experimentation with mind altering substances Prescription drugs and painkillers readily available • Vietnam war: use of cannabis by troops and anti-war protestors

6. 1970s and 80s • Alcohol and drug experimentation continued: cannabis, LSD, heroin • New treatments • Decreasing mortality due to infections • Increasing concern with chronic diseases • Increasing longevity

7. Now and the future Number of adults aged 50 or older with substance use disorder projected to double by 2020 Outcomes of problematic substance used different when older • Heighted sensitivity/ reduced tolerance - same level of alcohol will have an increased effect • Physiological changes (smaller body volume/mass) = increased impact • Accelerated ageing: impaired cell regeneration and increased rates of cell death • When 40: biological age of 60 • Heightened use of medications that interact with alcohol, such as sedatives and tranquillisers Women’s use converging with men’s: roles changed dramatically • Increased alcohol use • Telescoping of outcomes – women become sicker quicker

8. Therefore more older Australians with alcohol use problems BUTAt the individual level marginalised groups carry the burden of poor health associated with alcohol usePeople who experience homelessness

9. Association between alcohol use and homelessness in older people • Substance use patterns more risky • exposed to elements and violence, poor nutrition, lack of opportunites for hygiene • Alcohol problems and traumatic brain injury highly prevalent • History of homelessness + problematic alcohol use + traumatic brain injury = accelerated cognitive deficits • BUT do not necessarily meet the age criteria for access to services although meet physical criteria • THEREFORE Little or no targeted services available for this group

10. Study aims and methods Aim: To describe the association between alcohol use and cognitive processes in older homeless people and implications for serices Method: • 50 Face-to-face client participant interviews • Assess demographics, physical and mental health, social support, cognitive performance, use of services • Series of in-depth interviews with key experts in the areas of aged care and homelessness to determine “gold standard” in care for homeless people who are also alcohol dependent.

11. Methods • Clients were recruited from Haymarket Centre for homeless people in inner Sydney. • Eligible if 45 years or older and homeless in past 6 months. • Homelessness defined as: • Primary homelessness: sleeping rough on the street or in a car or other makeshift dwelling • Secondary homelessness: staying in an accommodation service, hotel or motel, or staying with family or friends because they had nowhere else to live • Tertiary homelessness: living in a boarding house/hostel or caravan (insecure tenure)

12. Demographics

13. Almost all participants had ever slept rough (94%) and stayed in crisis accommodation (90%). A little over one half of the sample had also stayed with friends or family and one third had stayed in a caravanCycling though different types Homelessness history

14. Cycles of homelessness The earliest mean age of onset for the different homelessness states • 25 years of age for staying with family and friends • 26 years for staying in a caravan, • 29 years for boarding/rooming house, and • 31-34 years for sleeping rough, crisis accommodation and staying in a motel. This pattern suggests participants experienced precarious housing situations before first experiencing primary homelessness and accessing supported accommodation services.

15. Health issues Uncontrolled chronic conditions; mental health, asthma and epilepsy BSI: 98th percentile for psychological distress

16. Alcohol use 95% lifetime alcohol dependence/ 75% currentl alcohol dependent

17. % Past month substance use

18. Alcohol Related Brian Injury • Brain organ most sensitive to the toxic effects of chronic alcohol consumption • International literature: high exposure to brain injuries from falls and assaults and injuries • Wernickes encephalopathy: Direct result of alcohol use: thiamine deficiency • Persistent learning and memory problems. • Forgetful and quickly frustrated and have difficulty with walking and coordination. • Korsakoffs psychosis: problems remembering old information (i.e., retrograde amnesia), but “laying down” new information (i.e., anterograde amnesia) that is the most striking. • For example, these patients can discuss in detail an event in their lives, but an hour later might not remember ever having the conversation.

19. Brain injury • Prevalence of any acquired brain injury (ABI) 88% • Montreal cognitive assessment ; mild cognitive impairment • similar scores to people with Alzheimer's Disease • Brief Symptom Inventory scored in 98th percentile for psychological distress • Suggests there is a need for neuropsychological assessment in this group.

20. Degree of impairment among homeless persons who screened positive for MCI on the MoCA Average: 22, 77% had mild cognitive impairment

21. So, what will we see? • More older Austrlians who are homeless and alcohol dependent • Late onset disorders related different factors • retirement; loss of income, loss of significant others (spouse/partner/children) • Poor mental health : mood and anxiety disorders, psychoses and cognitive disorders e.g dementia, delirium and Wernicke-Korsakoff syndrome. • Poor physical health: osteoporosis; ischemic heart disease, stroke, type 2 diabetes, colorectal cancer, infection, poor dental care, , lung cancer bronchitis (smoking), falls, liver cirrhosis, dementia, and adverse events arising from medication mismanagement. • End stages of long standing BBVs – HIV, Hep C, Hep B • Increased social exclusion: sever links with family and non-drug using friends, death of partners

22. The way forwardHarm minimisation as an approach to care • This group have high rates of alcohol use disorders hence increased cognitive deficits on top of normal ageing • More than ne-third scored similar to Alzheimers disease sample • Elderley homeless age early • But access to aged services largely based on age • What is the best model for elderley homeless? • ? Appropriateness of aged services for younger individuals • Cognitive impairment as a result of drinking can improve with a reduction in alcohol use

23. Key experts: Principles of treatment • Respectand dignity “Irrespective of presence of brain injury or anti-social behaviour these individuals are entitled to receive care and support that is both appropriate to their needs and which promotes empowerment and independence” 2. Fitting service to client • Understanding client with respect to ARBI – prone to aggression • Need to understand and manage trigger points • Trained staff/ consistency / expertise/ assists client to develop repoire and trust • Structure: but flexibility “I think you have be extremely sensible in your rules and be prepared to bend a bit, because you will always come up against people who are completely different and a different approach works”

24. 3. Security and privacy • Need for own space that cannot be violated • Previous history of theft and assault need safe place to go “if they've been on the streets that security of being able to go into their room and lock it and feel safe is also extremely important”

25. 4. Harm minimisation • Prescribed low level but regular alcohol use • In agreement with client / may opt to later when see effective for others: doesn't have to be in detox /rehab • Reduces anxiety around running out of alcohol • Some people become abstinent / don’t want dose every time = allows for behavioural change if not in state of high anxiety “They are quite willing to make changes and are able to implement them but just can’t maintain them, so the approach overall becomes much more extended and focussed on harm minimisation”

26. 5. Managing Alcohol Related Brain Injury Treatment for ARBI = Controlled drinking + nutrition + longer treatment + housing + meaningful individually matched activities

27. Model Stability of housing + medical care • Regular nutrition / diet plus supplements + compliance with regular medication + roof over head + improvement in impairment associated with ARBI = huge difference in whole well being Very possible to return to social and economic participation

28. Broad conclusions • Expect unprecedented rise in morbidity related to alcohol and drug use in older people with problematic substance use • This will lead to increased need for specialist treatment services Models of care should target individuals with different degrees of disability • For individuals who are substance dependent the needs will differ • Health conditions will differ e.g. BBVs, cancer and be more severe • Substance related brain injuries needs to be accounted for

29. Broad conclusions cont..... • Framework of care • Respect • Structure but matched to person • Diet and nutrition • Harm minimisation related to drug use “Individuals who are most marginalised will carry the burden” Further details: Lucy Burns l.burns@unsw.edu.au THANK YOU