‘Older people, alcohol and other drugs’

Dr Barbara HunterProf Dan Lubman

Definitions “Older people”

Describes people >60yrs Encompasses vast array of

different people with very different physical and psychological needs (cf. people in their 60s with 80s)

Definition of “older people” varies in the literature (55, 60 or 65 plus)

Older Australians – key facts Older Australians constitute 13.6%

of population (24% by 2051) Health of older Australians has been

identified as a key economic and medical challenge for the coming decades

Ageing is associated with biological changes in the metabolism of alcohol and other drugs

Estimated that 25% consume 5 or more prescription medications concomitantly

Trends in AOD consumption in older people

15%

5%

8%

3%

12%

10%

15%

2%

0%

2%

4%

6%

8%

10%

12%

14%

16%

Drink daily Short-term risk Smoke daily Prescription drugs

Popu

lati

on p

reva

lenc

e

Over 65 yrs

55 to 65 yrs

Source: NDSHS

Drugs of concern: alcohol

Is the most commonly consumed (and misused) drug among people >60yrs

Older people are more likely to consume alcohol daily than other age groups & are more likely to be consuming multiple prescription medications

In 2007, 15% of people aged >65yrs consumed alcohol daily & 5% were at risk of short term alcohol related harm

Alcohol use in a community based sample of elderly men: associations with physical and mental health

Carolyn CoulsonA/Prof Julie PascoDr Lana WilliamsProfessor Michael BerkProfessor Dan Lubman

Method: Baseline sample

Design: a population-based observational study

Participants were an age stratified, random sample of the community enrolled in the Geelong Osteoporosis Study (GOS)

N=1,420 men (20yrs+) N=554 men (65yrs+)

Usual number of drinks per day

Total None 1-2 3-4 5 P value

n=554 n=100 n=270 n=109 n=75

Age (year) 76.0 (71.0-82.0) 78.5 (72.3-83.0) 77.0 (72.0-83.0) 76.0 (69.5-81.0) 73.0 (69.0-78.0) 0.001

Body composition

Height (cm) 171.5 ± 6.8 170.8 ± 6.2 171.3 ± 6.9 171.8 ± 6.8 172.7 ± 6.8 0.29

Weight (kg) 74.9 ± 13.4 77.5 ± 15.1 79.3 ± 12.6 80.3 ± 11.1 84.8 ± 15.8a 0.004

BMI (kg/m2) 27.2 ± 4.1 26.6 ± 4.9 27.0 ± 3.7 27.2 ± 3.4 28.4 ± 4.7a b 0.03

BMI groups 0.005

<25 (kg/m2) 158 (29.4%) 40 (43.0%) 75 (28.3%) 30 (28.3%) 13 (17.6%)

25-29.9 (kg/m2) 267 (49.6%) 35 (37.6%) 138 (52.1%) 57 (53.8%) 37 (50.0%)

> 30 (kg/m2) 113 (21.0%) 18 (19.4%) 52 (19.6%) 19 (17.9%) 24 (32.4%)

Waist circumference

(cm) 100.0 (93.5-107.0) 98.0 (90.0-107.0) 99.0 (93.0-106.5) 101.0 (95.0-105.0) 103.0 (97.0-11.5) 0.008

Waist ³ 102cm 228 (43.9%) 35 (38.9%) 108 (42.0%) 48 (46.6%) 37 (53.6%) 0.24

Waist hip ratio 0.98 ± 0.05 0.98 ± 0.06 0.99 ± 0.05 0.99 ± 0.05 1.00 ± 0.05 0.16

% Fat mass 27.0 ± 6.6 25.7 ± 7.7 26.5 ± 6.2 28.0 ± 6.2 29.2 ± 6.7a b 0.001

% Lean mass 69.2 ± 6.3 70.5 ± 7.3 69.7 ± 5.9 68.2 ± 6.0 67.1 ± 6.4a b 0.001

Blood pressure

(mmHg)

Systolic 141.5 (130.5-157.5) 138.0 (130.5-152.1) 141.5 (128.5-159.6) 140.8 (132.5-151.0) 144.3 (133.3-158.1) 0.61

Diastolic 84.0 (76.0-93.1) 81.8 (74.9-92.6) 84.3 (77.8-93.0) 85.0 (76.0-95.4) 84.3 (75.5-92.0) 0.57

Adjusted for age, cigarette smoking and current use of 5+ medications

a: Significantly different from ≤2 drinks/dayb: Significantly different from 3-4 drinks/d

0

5

10

15

20

25

30

Any

psychopathology

mood disorder

(ever)

Mood disorder

(current)

A nxiety disoder

(ever)

Anxiety disorder

(current)

Current mood or

anx iety disorder

%

None

1-2

3-4

5+

Drugs of concern: prescription drugs

Prescription drugs next most commonly used & misused (although at very low levels)

Growing awareness of potential pharmaceutical drug misuse among older people (e.g. benzos)

3% of older people reported using pain killers or non-opioid analgesics for non-medical purposes

Drugs of concern: illicit drug use

Based on US research, there is concern that higher levels of illicit drug use may be seen in Australia among older people as the ‘baby boomers’ enter their 60s, 70s & 80s

Women are less likely to abuse illicit drugs but are more likely to engage in problematic use of alcohol or prescription drugs

AOD misuse in older people

62% Alcohol only

22%Benzos only

16%Other

AOD related ambulance attendances, 65+

Source: Ambulance VictoriaYear: 2010

Hospital admission & ambulance attendance data

Analysis of Victorian hospital admission & ambulance attendance data showed an increase in the rate of older people (>65yrs) experiencing significant alcohol-related harm (Hunter, Lubman & Barratt 2011)

Ambulance attendance rates for alcohol intoxication:

2004: 3.3 persons per 10,000 persons 2008: 8.2 persons per 10,000 persons

Hospital admission rates for alcohol intoxication: 2004: 64.5 persons per 10,000 persons 2008: 73.9 persons per 10,000 persons

AOD misuse in older people

17%Alcohol

82%Tobacco

1%Other

AOD related hospital admissions, 65+ (2004-08)

Source: VAED

AOD misuse in older people

65+ years1%

Under 64 years99%

Proportion in AOD treatment by age group

Source: ADIS

AOD misuse in older people

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

2006 2007 2008 2009

Proportion of pharmacotherapy clients aged 60+

Source: AIHWYear :2010

Factors influencing consumption

No studies in Australia that map changing patterns of AOD use in older people

Factors that may influence use (and misuse) of alcohol: Attitudes of social group (e.g.

supportive of heavy drinking) Financial resources Life history of alcohol

consumption Health (e.g. a decline in health

may lead to reduced drinking) Use of alcohol as a coping

strategy (e.g. pain, bereavement, anxiety and/or depression)

Categorisations of misuse: identifying the problem & treatment decisions

Early onset AOD misuse – long term problems Can be associated with a range of physical health

impacts and an increased likelihood of psychiatric & medical co-morbidity in old age

Late onset AOD misuse – recently developed problems Positive or negative lifestyle changes may influence

onset e.g. retirement, loss of spouse or close friends, loss of health, increase in free time, reduced responsibilities, changing peer group

Inappropriate prescribing or unintentional misuse of pharmaceutical drugs can result in adverse drug reactions

Health impacts of AOD use Health impacts of risky/high risk

alcohol consumption Alcohol liver cirrhosis, haemorrhagic

stroke, falls, hip fracture, cardiac arrhythmias, alcohol dependence, reduced cognitive performance, adverse drug reactions, worsening mental health, increased suicide risk

Limited evidence supporting health benefits of moderate alcohol consumption

Ageing bodies gradually lose the ability to metabolise alcohol & other drugs making co-occurring conditions more likely, especially for women

Treatment seeking: a hidden issue

Currently few older people within specialist AOD treatment system in Australia. Why? Health care practitioners: lack

of awareness, reluctance to ask, may mistake symptoms of alcohol related harm for other health problems

Older people: lack of awareness, sense of shame, reluctance to discuss

Early identification What to ask?

Few simple questions about AOD use (amount, frequency)

AUDIT-C, ARPS (Alcohol Related Problems Survey: higher sensitivity with older adults), ASSIST

When to ask? When doing any assessment (red flags:

falls, gastric complaints)

How to ask? As part of routine assessment, without

emphasis, not hurried

NB: Include medication assessment – high risk of adverse reactions in cases of 4+ medications

Examples of AOD treatment and/or screening programs

The Older Wiser Lifestyles (OWL) program Specialist AOD treatment for older people

(Peninsula Health)

Florida Brief Intervention and Treatment for Elders (BRITE)

Emergency & primary care settings for ≥55yrs

Reconnexions For problems associated with benzodiazepine

use. Program not specifically designed for older people but adaptable to needs of older population

Facilitating treatment delivery to older people

Promote alternate strategies to manage insomnia and stress

Outreach services Flexible length of treatment Age-specific group sessions, or embedding a social

component into the treatment program Co-location of services or strong co-ordination of care

providers (primary health care & AOD support) Incorporate the biological, mental health, social, physical

& spiritual needs of the client into treatment Install ramps & hand rails, use appropriately-sized text,

provide appropriate seating, minimise distance to be travelled within the service, provide transport to and from the service

Prevention activities Health promotion activities:

public education, appropriate warning labels on pharmaceutical drugs, population-specific education activities

Preventive health services: early identification & effective interventions

Little activity on these fronts in Victoria, except OWL program (Peninsula Health)

Treatment implications

Older people with AOD misuse disorders may not be identified Need to embed screening for AOD in a

range of client/patient contact situations Multiple medications and AOD use may

result in adverse consequences Prescribers need to enquire about and

consider current AOD when prescribing

Treatment implications

Services not established to cater to the AOD needs of older people Secondary consultation model whereby

AOD services consult with geriatrician, aged care services consult with AOD specialist

Older people may require support from multiple services Cross sector case management

approach

Future research opportunities

Identifying factors that motivate use and changes in use of AOD as people age

The influence of culture, social norms & peer influences on AOD use in older people

Social, economic, physical & mental health harms associated with AOD use by older people

Identifying a level of AOD consumption that is ‘safe’ or low risk for older people

Development and evaluation of AOD treatment models/programs targeted at older people

Acknowledgements

Geelong Osteoporosis Study Carolyn Coulson A/Prof Julie Pasco Dr Lana Williams Prof Michael Berk

Population Health – Turning Point Sharon Matthews Dr Belinda Lloyd

ADF