Substance misuse in older peopleBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3885 (Published 22 August 2017)Cite this as: BMJ 2017;358:j3885
Developed countries have seen substantial increases in longevity over the past 20 years, contributing to a global demographic shift. The number of older people (aged over 50) experiencing problems from substance misuse is also growing rapidly, with the numbers receiving treatment expected to treble in the United States and double in Europe by 2020.1
In both the UK and Australia, risky drinking is declining, except among people aged 50 years and older.23 There is also a strong upward trend for episodic heavy drinking in this age group. This generational trend is not restricted to alcohol. In Australia, the largest percentage increase in drug misuse between 2013 and 2016 was among people aged 60 and over, with this age group mainly misusing prescription drugs. However, people over 50 also have higher rates than younger age groups for both past year and lifetime illicit drug misuse (notably cannabis).4
Of additional concern is the increasing proportion of women drinking in later life, particularly those whose alcohol consumption is triggered by life events such as retirement, bereavement, change in home situation, infrequent contact with family and friends, and social isolation. The rise of alcohol misuse in “baby boomers” (people born between 1946 and 1964) has also been noted in Asian countries.5
Older people with substance misuse show different characteristics but most fall into one of three groups: maintainers (unchanged lifetime patterns), survivors (long term problem users), and reactors (later uptake or increased patterns). The distinction is important because each requires different assessment, intervention, and treatment regimens.6
With alcohol being the most common substance of misuse among older people, underdetection of alcohol problems is of immediate concern. Alcohol misuse in the older population may increase further as baby boomers get older because of their more liberal views towards, and higher use of, alcohol. A lack of sound alcohol screening to detect risky drinking may result in a greater need for treatment, longer duration of treatment, heavier use of ambulance services, and higher rates of hospital admission.
Two systematic reviews of both descriptive and analytical trials found that treatment programmes adapted for older people with substance misuse were associated with better outcomes than programmes aimed at all age groups.78Age adapted programmes resulted in less severe addiction, higher rates of abstinence, improved health status, and better aftercare. Assessment, treatment, and recovery plans require careful consideration of age specific clinical needs. Professionals need to consider the possibility of coexisting mental disorders such as cognitive impairment and depression (dual diagnosis), as well as complex physical presentations that may include the presence of pain, insomnia, or the non-medical use of prescription drugs. Older people with dual diagnosis use both inpatient and outpatient services more frequently than those with substance misuse alone.9 The management of substance use in older people can also be influenced by mental capacity, which may change with the onset of cognitive impairment.
Future healthcare for older people with substance misuse will continue to present challenges for service delivery, particularly with the growing influence of baby boomers. Some of the recommendations from the 2011 Royal College of Psychiatrists’ report on substance misuse in older people (Our Invisible Addicts),10 such as examining safe drinking limits for older people, developing age specific skills in the assessment and treatment of substance misuse, and adapting services have been incorporated into an information guide for clinical practice.11 In the United States, the importance of better education for clinicians has already been noted.12 In the UK, a revision of Our Invisible Addicts is under way.
The baby boomer population also brings challenges to the diagnostic process, given the complexity of clinical presentations. Clinicians will need improved knowledge and skills in assessing and treating older people at risk of misuse of opiate prescription drugs, cannabis, and, increasingly, gabapentinoid drugs used to treat neuropathic pain and anxiety.13
Guidance for service commissioners has begun to acknowledge the needs of older people with substance misuse, particularly in the context of dual diagnosis.14 The Drink Wise Age Well project in the UK has also started to evaluate interventions for alcohol misuse in older people.15 But there remains an urgent need for better drug treatments for older people with substance misuse, more widespread training, and above all a stronger evidence base for both prevention and treatment.
The clinical complexity of older adults with substance misuse demands new solutions to a rapidly growing problem. So far, there has been little sign of a coordinated international approach to integrated care.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned; externally peer reviewed.