Key points

Substances are drugs that alter mental state and are potentially addictive.

Substance abuse is not confined to the younger population; it is also prevalent in older people—alcohol and prescription drugs are the most commonly misused in this population.

The possibility of substance misuse should not be dismissed because of the patient’s age.

Recommended alcohol limits are likely to be lower than for younger adults.

Risk factors differ for older people, e.g. bereavement, retirement, loneliness, boredom.

Substance misuse is often accompanied by other mental and physical disorders.

Older people can improve with treatment so should be comprehensively assessed and offered evidence-based treatment regimes that are adjusted to take their special needs into account.

1 Introduction

Substances (Box 10.1) may be used appropriately (e.g. alcohol consumption within recommended ‘safe’ limits or medications taken as advised) or misused (taken illegally or against medical advice; e.g. smoking tobacco). Although use and misuse may have consequences for the user, regular, heavy, and risky use may result in dependence or addiction in all age groups including older people. Substances or substance misuse contribute to the burden of disease, are highly prevalent, and reduce life expectancy.

Box 10.1 Definition of substance and substance misuse

In this chapter, ‘substance’ is used to describe licit substances (tobacco and alcohol) and illicit substances (opiates and opioids such as heroin and methadone, stimulants such as cocaine, amphetamine, and ecstasy). The term is also used to describe use of prescription drugs or medications bought over the counter and used in a manner not in accordance with medical advice.

The term ‘older’ is generally used to denote over the age of 65, but if the information is based on younger age groups, this will be stated.

By 2020 older people over the age of 65 years will constitute 25% of the population in the UK. National surveys, attendances at accident and emergency units, presentations to specialist addiction services, and hospital admissions for poisoning, drug, and alcohol-related mental and physical disorders indicate that there is an increasing number of older people seeking help for substance misuse (1–4). Based on these indicators, the prediction is that the number of older substance misusers will double in the next two decades.

Substance misuse is a major financial burden in the UK due to costs incurred to the health service and the criminal justice system, as well as poor productivity in the workplace. There are also wider social costs to families, friends, and wider communities, such as homelessness or divorce, that are not included in economic estimates.

Tobacco, alcohol, and illicit drugs are three of the top eight risk factors contributing to the burden of disease in Europe. The current prevalence rates of substance use in the UK reflect this concern. Approximately 13% of older men and 12% of older women still smoke cigarettes, and smoking remains the largest cause of premature death (5). Alcohol consumption above the ‘safe’ or ‘sensible’ limits for adults is found in 20% of men and 10% women over the age of 65 (3, 6). This might well underestimate the impact on older people since the recommended ‘safe’ limit for adult men is 3–4 units of alcohol each day and no more than 21 units each week, while that for women is 2–3 units of alcohol each day and no more than 14 units each week. One unit is equivalent to 8 g pure alcohol. However this may not be appropriate for older people (7). Conservative estimates of the costs of substance use overall to society, and specifically for older people where available, are shown in Box 10.2.

Box 10.2 Alcohol-related costs

It is estimated that alcohol costs the country approximately £21 billion per year and illicit drugs cost £15 billion per year.

The costs are greater for older people.

The costs ofhol-related inpatient admissions in England for 55–74-year-olds (£825.6 million) were more than ten times that for 16–24-year-olds (£63.8 million).

Eight times (317,454) as many older people were admitted compared with younger people (54,682).

Alcohol-related inpatient admissions cost £1,993.57 million, compared with A&E admissions, which cost £636.3 million.

The cost of male inpatient admissions (£12,784 million) was almost double that of women (£715.1 million) since more men were admitted.

Source: National Information Centre. Statistics on alcohol: England 2011. Health and Social Care Information Centre. <http://www.hscic.gov.uk/pubs/alcohol11>

Furthermore, alcohol-related mortality has trebled since 1984, with the greatest rate of increase in the 55–74 year age group. The highest numbers of new presentations in drug treatment units are people over 40 years, which constitutes 17 per cent of their clients. Nearly half the medications prescribed in the NHS are for over-65-year-olds. In the adult population it is estimated that substance misuse can reduce life expectancy by up to 17 years, and if combined with a serious mental illness (which is commonly the case), by a further 13 years (8, 9).

2 Diagnosis of addiction in older people

A diagnosis of dependence (commonly referred to as ‘addiction’) depends on having three or more of the following criteria over the previous 12 months: tolerance, withdrawal, and relief of withdrawal, inability to control use, compulsion to use, increased time spent obtaining substances, reduction of activities or obligations due to use, and continued use despite the development of physical and psychological consequences (3). It should be noted that these criteria were developed in the adult population and therefore should be applied cautiously in older people where the quantity and frequency of use may be as relevant as dependence criteria in establishing the impact of substance use on the presentation.

2.1 Competence in the comprehensive assessment as prelude to treatment

Problematic substance use can have long-term implications; it can be complex and chronic, necessitating management in partnership with the patient and family. First, however, the condition needs to be detected. There are barriers to identification by professionals that need to be overcome. The Royal Medical Colleges are working collaboratively to ensure that all medical professionals are trained in terms of their attitudes to substance misusers, knowledge about the problem, and requisite skills to competently diagnose and treat substance misusers. A non-judgemental and non-confrontational approach is key not only in treatment but also in assessment. In order to obtain a detailed history, practitioners need to be aware of subtle atypical presentations. They also need to have a high index of suspicion and to guard against ageist perceptions, stereotyping, stigmas, and myths such as ‘at their age what does it matter, that is all s/he has left, treatment does not work’.

There are several screening tools available for the detection of substance problems in older people. In busy clinical practice, the most useful are the SMAST-G (Short Michigan Alcoholism Screening Test–Geriatric version), AUDIT (Alcohol Use Disorders Identification Test), and the recently developed DAPA-PC (Drug and Alcohol Problem Assessment for Primary Care). This latter is a computerized screening system that quickly identifies problems as is a self-administered, Internet-based instrument which generates a patient profile for medical reference and presents advice for the patients. Clinicians follow up if needs be. This offers a new way forward to assess patients in the future (11).

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