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ILANA CROME

ILANA CROME. Professor of Addiction Psychiatry, Keele University Medical School United Kingdom Chair Working Group Older Substance Misusers Royal College of Psychiatrists Past President Drug and Alcohol Section, Association European Psychiatrists

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ILANA CROME

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  1. ILANA CROME Professor of Addiction Psychiatry, Keele University Medical School United Kingdom Chair Working Group Older Substance Misusers Royal College of Psychiatrists Past President Drug and Alcohol Section, Association European Psychiatrists Past Chair, Addiction Faculty, Royal College of Psychiatrists

  2. ALCOHOL AND OTHER DRUG USE AMONG OLDER PEOPLE BRITISH ASSOCIATION OF SOCIAL WORKERS MANCHESTER 9 MARCH 2010

  3. Being older is…………… ageless

  4. Being older is:

  5. Being older is:

  6. MYTHS ABOUT ADDICTION AND OLDER PEOPLE • At your age what does it matter? - negativity • It is just a phase - you grow out of it - denial • It’s your age – there is nothing you can do about it – resignation • Illicit drug use: no longer a young man’s disease - fact • Drug use and the older person – a contradiction in terms? – No!

  7. Cannabis case grandmother is spared prison

  8. Substance misuse is:

  9. Introduction • 17% of the UK population is over 65 years old • This proportion will increase • Alcohol related deaths in UK doubled form 1991-2005 • Highest death rate from alcohol among those aged 55-74 • Smoking is the largest cause of premature death in UK2. • Older people use at least twice as many prescription drugs as younger people

  10. What particular risks do older people face? • Older people are particularly at risk from effects of substances due to changes in metabolism • Assessment is key - Under-diagnosis of substance use and misuse may have contributed to lower known levels of misuse • Presentation may be subtle and easily missed • Current evidence based treatment guidance does not include people over 50 years old. Age range > 40 years

  11. Projecting drug use among aging baby boomers in 2020? (Colliver et al 2006)

  12. Comorbidity rates stratified by age -band & type of substance use (annual comorbid cases) – licit dependence in age 55

  13. Is it a problem? • Over the last ten years there has been an overall increase (numbers and rate) in older people • Using illicit substances and alcohol • Hospital admissions for poisoning, drug related mental disorders, alcohol related physical disorders • Drug related deaths and alcohol related deaths • Usually men > women, older usually use less

  14. Vignette • A 60 year old man was found wandering around his local area picking up cigarette stubs and begging for money to buy alcohol. He was very disheveled. • Neighbours said that he had lost his job several months previously, because he had been drinking heavily. He had had chest pains and asthma and had been noted to have hypertension. He had not taken the treatment for his cardiovascular problems for several months. • He was not eating properly and was neglecting himself. He had had a period of heavy drinking years ago, but had managed to cut down. • His wife died suddenly and his social network seemed to have contracted to such an extent that he was isolated and bored, especially at the weekends. • He had therefore taken to drinking regularly. • On admission to a geriatric unit, he was diagnosed as having alcohol-induced dementia.

  15. Vignette • A specialist registrar was called to see a 69 year old man in the surgical ward, who was extremely agitated and distressed. • He was attending for assessment for inpatient admission. • Although he had drunk seven pints of cheap cider that morning he was tremulous, sweaty and confused. • He did not know the date and had difficulty walking. He was depressed and said that he wanted to die. He complained of failure and guilt in relation to his children and felt hopeless about the future. He was unemployed and living alone. • His blood pressure was 168/102 and his pulse rate was 100. After several hours at the service it became clearer that he was in severe alcohol withdrawal and so he was admitted immediately for detoxification and assessment of his mental state.

  16. Invisible or hidden ‘epidemic’ – high index of suspicion • Missed, neglected, overlooked, misinterpreted • Altered or erratic: mood, memory, self-harm, anxiety • Isolation: loss of spouse, friends, family, income, job • Insomnia, sleepiness, drowsiness, delirium, confusion • Pain, psychomotor and performance diminished

  17. ALCOHOL • Level of risk = malaria, TB, measles • Pharmacology • Toxicity • Withdrawal • Deficiency syndromes • Domestic violence • Drink driving injury

  18. Alcohol – Central nervous system effects • No absolute threshold below which there are no effects • BAC 25 mg% euphoria • BAC 50-100 mg% lack of coordination • BAC 100-200 mg% unsteadiness, ataxia, poor judgment • BAC 200-400 mg% periods of amnesia • BAC 400-700 mg % Coma

  19. Alcohol intoxication • Increased risk of other pathologies eg trauma from head injury • Age, sex and degree of dependence alter presentation • High tolerance may be associated with high alcohol levels with low levels of impairment • Low alcohol dose in the elderly is associated with greater subjective perception of intoxication and the effects last longer; alcohol effect on psychomotor ability more detrimental in older people

  20. Alcohol withdrawal • Precipitated by lack of money, acute illness, nausea and vomiting • Mild moderate severe continuum • Greater in older people, and can follow infrequent or low volume drinking • Seizures, hallucinations and delirium are major symptoms • Seizures occur after about 12-48 hours, due to toxicity, withdrawal, trauma

  21. Alcohol deficiency states • Thiamine deficiency • Wernicke Korsakoff syndrome – reversible condition, but can fatal if not treated • WK – ocular, ataxia and confusional state • Korsakoff’s – lack of insight, apathy, amnesia • Dementia – neuronal loss –major problem

  22. Other alcohol related damage • Liver and gastrointestinal disorder • Cancer • Cardiovascular disorder • Muscle disorder • Bone disease • Skin disease

  23. DRUGS • Pharmacology • Quantity • Toxicity • Route of use • Contaminants • Purity

  24. Benzodiazepines • In the elderly, multiple stressors, way of coping, underestimate the risks, hoard, previous failed attempts at reduction • Dizziness, tiredness, unsteadiness • With alcohol and opiates overdose can be fatal • Dependence on low doses • Convulsions on withdrawal

  25. Opiates • Overdose and death due to depressed respiration • Injected, oral or suppositories – in pharmaceutical formulations eg cocodamol –codeine based • Heroin - Inhaled, snorted, crushed, smoked, injected IV, IM, Subcutaneously • Dependence develops rapidly • Craving, sweaty, shivers, aches

  26. Cannabis • Depression, anxiety and paranoia • Panic attacks • Psychosis – exacerbated, and possibly ‘causes’ • Cancers of head and neck, and lung cancer

  27. Amphetamine and cocaine • Anxiety, exhaustion, depression and weight loss • Paranoid and/or confusional state occur • Violent and aggressive behaviour • Intravenous use of cocaine may result in fits, stroke and cardiac pain

  28. WHAT TO LOOK FOR? • Amnesia • Psychomotor performance diminished • Pain • Bereavement, loss and loneliness • Past history or family history of substance misuse • Investigations: LFTs, metabolic (cholesterol, urate, glucose)

  29. WHAT TO LOOK FOR, WHERE? • Setting: WHEREVER - general psychiatric and medical wards, nursing homes, care homes, homes • Change – unpredictability • Unkempt • Erratic mood and behaviour • Sleep: insomnia, oversleeping, drowsiness • Sharing medication with family, friends, acquaintances

  30. Predictors of late life drinking (Schutte et al) • History is important even if patients are in remission because of financial, health and life context deficits which have lasting effects (Schutte et al 2003) • Smoking, friends’ approval, avoidance coping predict late-life drinking problems • Heavy drinking, problems, response to life events by drinking related to late life drinking • Help from family and friends related to lower likelihood

  31. Health conditions among ageing addicts Hser et al 2004 • 108 survivors 58.4 years (33 year cohort) • Used heroin for 29.4 years • Current use : 84% used cigarettes, 17.6% drank alcohol daily, 23% heroin, 21% marijuana, 11% cocaine. 6% amphetamines • 51% hypertension, 22% hyperlipidemia • 13% elevated blood glucose, 50% overweight • 33% abnormal pulmonary function

  32. Health status • 50% abnormal liver function • 94% tested positive for Hep C, 86% for Hep B, 3.8% for syphilis and 27% for TB • Perceived themselves as having worse physical functioning, worse emotional well being, less energy and worse general health when compared to the general population • Probably conservative estimates

  33. Older opiate addicts (Sidhu et al 2007) Health Problems

  34. Results: Profile of Older Opiate Misuser in Stoke-On-Trent • Age range 45-55 years • 95% of cohort were white Caucasian males • 85% were single at time of study; 50% had separated/divorced by age 35yrs. • Limited education: 65% had no qualifications; 30% had between 4-9 O levels. • 90% were currently unemployed; 10% have never been in employment.

  35. Results: Substance Misuse History • Lifelong polydrug users: Licit drugs: Nicotine (100% of cohort) Alcohol (47%) Illicit drugs: Cannabis (75%), Amphetamines (60%), Crack (50%), Hallucinogens (20%) • Current substance use: Cannabis (55%), Crack (35%) and Benzodiazepines (35%)

  36. Results: Opiate Misuse History • Opiate use was usually started in late 20’s • Average age first exposed to heroin 29.8 years (range 16-46 years: SD=8.8years) • Average length of heroin use 18.5 years (range 6-38 years; SD-8.7years) • In 20% of cases a major life event had occurred prior to using heroin

  37. Results: Diverse Range of Health Problems • Special health needs highlighted Present in study in national guidelines Infectious disease • Hepatitis C √ (67%) • Hepatitis B √ (50%) • HIV X ( 0% - only 10% tested) Medical • Respiratory disease √ (25%) • Diabetes √ (10%) • Not mentioned Musculoskeletal pain (35%)

  38. Health problems • Special health needs highlighted Present in study. in national guidelines Cardiovascular • P.E./D.V.T √ (25%) • Venous/Arterial damage X Information not documented • Hypertension X ( 0%) (Inadequate information) • Cardiac valve destruction X (0%) (No documentation) Psychiatric • Self harm √ (42%) • Depression √ (40%) • Memory loss √ (25%)

  39. Special health needs • Despite the complaint of memory loss in 25% of cohort, in only 1 patient was mini mental state examination documented. • 40% sample with a respiratory complaint did not have a diagnosis or treatment plan. • 55% of cohort had no documentation of Hepatitis B and C status. • 15% sample were receiving opiate analgesia for musculoskeletal pain.

  40. Results: Treatment Outcomes • Positive outcomes • 50% in treatment for over 3 years. • All reported reduction in quantity of heroin used • Amount spent reduced from £300 to £20/week. • Reduction in intravenous administration from 70% to 5%. • ‘Negative’ outcome • Only 22% showed consistently negative opiate urine samples in the previous 6 months.

  41. Discussion • This is the first study of this kind in the UK • Treatment is associated with positive outcomes • The older substance misuser has a diverse range of health problems i.e. Social, physical and psychiatric • All special health needs may not have been identified as there was no routine screening • Where they were identified, they were • Not appropriately further assessed & investigated & monitored • Not treated by a comprehensive multidisciplinary team in liaison with other health practitioners

  42. Conclusions • Study has substantiated the special health needs which older substance misusers experience • Current national guidance does not provide evidence based management specific to older opiate users • UK guidance appropriate for this group needs further development in terms of4: • Screening & assessment • Specific treatment regimes & medication licences • Service delivery in multidisciplinary teams (e.g. geriatricians, old age psychiatrists, psychologists, physiotherapists, social workers, occupational therapists, nurses, health care workers, counsellors)

  43. Pharmacological treatments • Need to diagnose dependence • ON EACH DRUG SEPARATELY • Management of withdrawal symptoms eg benzodiazepines, carbemazepine; methadone, clonidine, lofexidine buprenorphine;nicotine replacement, bupropion • Maintenance of abstinence eg methadone, buprenorphine;nicotine replacement, bupropion

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