NEVER TOO OLD – NEVER TOO OLD – OLDER PEOPLE AND OLDER PEOPLE AND SUBSTANCE MISUSESUBSTANCE MISUSE

SCOTTISH DRUGS FORUMSCOTTISH DRUGS FORUM

GLASGOW GLASGOW

18 November 0918 November 09

Professor Ilana CromeProfessor Ilana CromeKeele University Medical SchoolKeele University Medical School

Chair, WG Older Substance Chair, WG Older Substance Misusers, RCPsychMisusers, RCPsych

Immediate Past President Drug and Immediate Past President Drug and Alcohol Section, European Alcohol Section, European

Psychiatric AssociationPsychiatric Association

Dr Alex BaldacchinoDr Alex BaldacchinoDirector Centre for Addiction Director Centre for Addiction

Research and Education Scotland Research and Education Scotland (CARES)(CARES)

Ninewells Hospital and Medical Ninewells Hospital and Medical SchoolSchool

Dundee University and NHS FifeDundee University and NHS Fife

OverviewOverview

•Prevalence and Prevalence and epidemiologyepidemiology

•Treatment evidence and Treatment evidence and outcomesoutcomes

•Practical interventionsPractical interventions

Substance misuse is:Substance misuse is:

MYTHS ABOUT ADDICTION MYTHS ABOUT ADDICTION AND OLDER PEOPLEAND OLDER PEOPLE

• At your age what does it matter? At your age what does it matter? • It is just a phase - you grow out of it.It is just a phase - you grow out of it.• It’s your age – there is nothing you It’s your age – there is nothing you

can do about it.can do about it.• Illicit drug use: no longer a young Illicit drug use: no longer a young

man’s disease?man’s disease?• Drug use and the older person – a Drug use and the older person – a

contradiction in terms? contradiction in terms?

Cannabis case grandmother is spared prison

Projecting drug use among Projecting drug use among aging baby boomers in aging baby boomers in

2020? 2020? (Colliver et al 2006) (Colliver et al 2006)

>50 years old>50 years old 1999/20011999/2001 20202020

Past year Past year marijuana marijuana usersusers

1% (719,000)1% (719,000) 2.9% (3.3 m)2.9% (3.3 m)

Any illicitAny illicit 2.2% (1.6 m)2.2% (1.6 m) 3.1% (3.5 m)3.1% (3.5 m)

Non-medical Non-medical useuse

1.2% 1.2% (911,000)(911,000)

2.4% (2.7 m)2.4% (2.7 m)

Prevalence Prevalence

A snap shot of A snap shot of

general population studies general population studies and and

clinical studiesclinical studies

Some methodological Some methodological issuesissues

• Invisible epidemicInvisible epidemic – ageism, denial by – ageism, denial by professionals and families, stereotypes, difficult professionals and families, stereotypes, difficult diagnosis, non-specificdiagnosis, non-specific

• Age variesAge varies from <55->75from <55->75 – alcohol metabolism – alcohol metabolism declines with age and results in greater damagedeclines with age and results in greater damage

• What is a standard drink or ‘What is a standard drink or ‘safe limitsafe limit’ for older ’ for older people? people?

• Other drug useOther drug use: prescribed, OTT, interactions: prescribed, OTT, interactions• TerminologyTerminology: application of use, misuse, : application of use, misuse,

dependence dependence • Medical Medical complications complications without being without being

‘dependent’‘dependent’

Some methodological Some methodological issuesissues

• GenderGender: women metabolise faster; more : women metabolise faster; more severe effects earlier or lower levels of severe effects earlier or lower levels of drinking; present later; more comorbidity drinking; present later; more comorbidity especially abuseespecially abuse

• MeasurementMeasurement: relevant, reliable, across : relevant, reliable, across substances and in combinationsubstances and in combination

• ComparabilityComparability between studies - between studies - Community studies miss out heavier Community studies miss out heavier drinkersdrinkers

Is it a problem for older Is it a problem for older people?people?

• Receive most prescriptions dispensed by NHSReceive most prescriptions dispensed by NHS• Multiple medications – 1/10 receive at least Multiple medications – 1/10 receive at least

one potentially inappropriate drug – (up to one potentially inappropriate drug – (up to 40%) 40%) (Lechevallier-Michel(Lechevallier-Michel et al 2004)et al 2004)

• 4 times greater in women (widowed, less 4 times greater in women (widowed, less educated, lower income, poor mental and educated, lower income, poor mental and physical health, social isolation)physical health, social isolation)

• Psychoactive medications with abuse Psychoactive medications with abuse potential are being used by 1 in 4 older potential are being used by 1 in 4 older people people (Simoni &(Simoni & Yang 2006)Yang 2006)

Is it a problem?Is it a problem?

• Over the last ten years there has been an Over the last ten years there has been an overall increase (numbers and rate) in older overall increase (numbers and rate) in older people people

• Using illicit substances and alcoholUsing illicit substances and alcohol• Hospital admissions for poisoning, drug Hospital admissions for poisoning, drug

related mental disorders, alcohol related related mental disorders, alcohol related physical disorders physical disorders

• Drug related deaths and alcohol related Drug related deaths and alcohol related deathsdeaths

• Usually men > women, older usually use lessUsually men > women, older usually use less

Is it a problem?Is it a problem?• Opiate dependent people do survive into old Opiate dependent people do survive into old

ageage• USA: Lifetime prevalence rates for illicit drug USA: Lifetime prevalence rates for illicit drug

dependence is 1% over 60s (Hinkin 2002)dependence is 1% over 60s (Hinkin 2002)• Alcohol consumption in GP Alcohol consumption in GP (Hajat et(Hajat et el 2004) el 2004) 5% men 5% men

drinking 2.5% women over benchmarksdrinking 2.5% women over benchmarks• Older opioid maintained patients Older opioid maintained patients Lofwall et al 2005Lofwall et al 2005

later in life, more medical problems, worse later in life, more medical problems, worse general health than youngergeneral health than younger

• Both groups had high rates of lifetime Both groups had high rates of lifetime psychiatric illness and substance use disorder psychiatric illness and substance use disorder and poor general health compared to general and poor general health compared to general populationpopulation

Health conditions among Health conditions among ageing addicts ageing addicts Hser et al 2004Hser et al 2004

• 108 survivors 58.4 years (33 year cohort)108 survivors 58.4 years (33 year cohort)• Used heroin for 29.4 years Used heroin for 29.4 years • Current use : 84% used cigarettes, 17.6% Current use : 84% used cigarettes, 17.6%

drank alcohol daily, 23% heroin, 21% drank alcohol daily, 23% heroin, 21% marijuana, 11% cocaine. 6% marijuana, 11% cocaine. 6% amphetaminesamphetamines

• 51% hypertension, 22% hyperlipidemia51% hypertension, 22% hyperlipidemia• 13% elevated blood glucose, 50% 13% elevated blood glucose, 50%

overweightoverweight• 33% abnormal pulmonary function33% abnormal pulmonary function

Health statusHealth status

• 50% abnormal liver function50% abnormal liver function• 94% tested positive for Hep C, 86% for 94% tested positive for Hep C, 86% for

Hep B, 3.8% for syphilis and 27% for TBHep B, 3.8% for syphilis and 27% for TB• Perceived themselves as having worse Perceived themselves as having worse

physical functioning, worse emotional physical functioning, worse emotional well being, less energy and worse well being, less energy and worse general health when compared to the general health when compared to the general population general population

• Probably conservative estimatesProbably conservative estimates

Older opiate addicts Older opiate addicts (Sidhu et al 2007)(Sidhu et al 2007) Health Health

ProblemsProblems

Results: Profile of Older Results: Profile of Older Opiate Misuser in Stoke-Opiate Misuser in Stoke-

On-TrentOn-Trent• Age range >50 yearsAge range >50 years• 95% of cohort were white Caucasian males95% of cohort were white Caucasian males• 85% were single at time of study; 50% had 85% were single at time of study; 50% had

separated/divorced by age 35yrs. separated/divorced by age 35yrs. • Limited education: 65% had no Limited education: 65% had no

qualifications; 30% had between 4-9 ‘O’ qualifications; 30% had between 4-9 ‘O’ levels.levels.

• 90% were currently unemployed; 10% 90% were currently unemployed; 10% have never been in employment.have never been in employment.

Results: Substance Misuse Results: Substance Misuse History History

• Lifelong polydrug users:Lifelong polydrug users:

Licit drugs: Nicotine (100% of cohort)Licit drugs: Nicotine (100% of cohort)

Alcohol (47%) Alcohol (47%)

Illicit drugs: Cannabis (75%), Illicit drugs: Cannabis (75%), Amphetamines (60%), Crack (50%), Amphetamines (60%), Crack (50%), Hallucinogens (20%) Hallucinogens (20%)

• Current substance use: Cannabis Current substance use: Cannabis (55%), Crack (35%) and (55%), Crack (35%) and Benzodiazepines (35%)Benzodiazepines (35%)

Results: Opiate Misuse Results: Opiate Misuse HistoryHistory

• Opiate use was usually started in late Opiate use was usually started in late 20’s20’s

• Average age first exposed to heroin Average age first exposed to heroin 29.8 years (range 16-46 years: 29.8 years (range 16-46 years: SD=8.8years)SD=8.8years)

• Average length of heroin use 18.5 Average length of heroin use 18.5 years (range 6-38 years; SD-8.7years)years (range 6-38 years; SD-8.7years)

• In 20% of cases a major life event had In 20% of cases a major life event had occurred prior to using heroinoccurred prior to using heroin

Results: Diverse Range of Results: Diverse Range of Health Problems Health Problems

• Special health needs highlighted Present in studySpecial health needs highlighted Present in study in national guidelinesin national guidelines

Infectious diseaseInfectious disease • Hepatitis C Hepatitis C √ (67%)√ (67%)• Hepatitis BHepatitis B √ (50%)√ (50%)• HIV HIV X ( 0% - only 10% X ( 0% - only 10%

tested)tested)Medical Medical • Respiratory disease Respiratory disease √√ (25%) (25%)• Diabetes Diabetes √√ (10%) (10%)• Not mentioned Musculoskeletal pain Not mentioned Musculoskeletal pain

(35%)(35%)

Health problems Health problems

• Special health needs highlighted Present in study.Special health needs highlighted Present in study.

in national guidelinesin national guidelines

Cardiovascular Cardiovascular • P.E./D.V.T √ (25%)P.E./D.V.T √ (25%)• Hypertension X ( 0%) (Inadequate Hypertension X ( 0%) (Inadequate

information)information)• Cardiac valve destruction X (0%) (No Cardiac valve destruction X (0%) (No

documentation)documentation)

PsychiatricPsychiatric• Self harm Self harm √√ (42%) (42%)• Depression Depression √√ (40%) (40%)• Memory loss Memory loss √√ (25%) (25%)

Special health needsSpecial health needs

• Despite the complaint of memory loss in Despite the complaint of memory loss in 25% of cohort, in only 1 patient was mini 25% of cohort, in only 1 patient was mini mental state examination documented.mental state examination documented.

• 40% sample with a respiratory 40% sample with a respiratory complaint did not have a diagnosis or complaint did not have a diagnosis or treatment plan.treatment plan.

• 55% of cohort had no documentation of 55% of cohort had no documentation of Hepatitis B and C status.Hepatitis B and C status.

• 15% sample were receiving opiate 15% sample were receiving opiate analgesia for musculoskeletal pain.analgesia for musculoskeletal pain.

Results: Treatment Results: Treatment OutcomesOutcomes

• Positive outcomesPositive outcomes– Methadone maintenance programme: 50% in Methadone maintenance programme: 50% in

treatment for over 3 years. treatment for over 3 years. – The present mean average dose was 51mls of The present mean average dose was 51mls of

methadone, but range of doses varied between methadone, but range of doses varied between 25mg/ml-94mg/ml.25mg/ml-94mg/ml.

– All reported reduction in quantity of heroin used All reported reduction in quantity of heroin used – In 60% of the group who were using £300/week In 60% of the group who were using £300/week

prior to treatment, amount spent reduced to prior to treatment, amount spent reduced to £20/week.£20/week.

– Reduction in intravenous administration whilst in Reduction in intravenous administration whilst in treatment (70% to 5%). treatment (70% to 5%).

• Negative outcomeNegative outcome– Only 22% showed consistently negative opiate Only 22% showed consistently negative opiate

urine samples in the previous 6 months. urine samples in the previous 6 months.

DiscussionDiscussion• This is the first study of this kind in the UK This is the first study of this kind in the UK • Treatment is associated with positive Treatment is associated with positive

outcomes outcomes • The older substance misuser has a diverse The older substance misuser has a diverse

range of health problems i.e. physical and range of health problems i.e. physical and psychiatricpsychiatric

• All special health needs may not have been All special health needs may not have been identified as there was no routine screeningidentified as there was no routine screening

• Where they identified, they wereWhere they identified, they were– Not appropriately further assessed & investigated Not appropriately further assessed & investigated

& monitored & monitored – Not treated by a comprehensive multidisciplinary Not treated by a comprehensive multidisciplinary

team in liaison with other health practitionersteam in liaison with other health practitioners

Conclusions Conclusions • Study has substantiated the special health needs Study has substantiated the special health needs

which older substance misusers experiencewhich older substance misusers experience• Current national guidance does not provide Current national guidance does not provide

evidence based management specific to older evidence based management specific to older opiate usersopiate users

• UK guidance appropriate for this group needs UK guidance appropriate for this group needs further development in terms offurther development in terms of4:4:

– Screening & assessment Screening & assessment – Specific treatment regimes & medication licencesSpecific treatment regimes & medication licences– Service delivery in multidisciplinary teams (e.g. Service delivery in multidisciplinary teams (e.g.

geriatricians, old age psychiatrists, psychologists, geriatricians, old age psychiatrists, psychologists, physiotherapists)physiotherapists)

Recommendations: Good Recommendations: Good practice – clinical practice – clinical governance issuesgovernance issues

• Supportive non-confrontational by trained Supportive non-confrontational by trained personnel who can prevent ridiculepersonnel who can prevent ridicule

• Inaccessible: homebound, transportation, Inaccessible: homebound, transportation, rural rural

• Create a safe environment, financial Create a safe environment, financial problems problems

• Explanations simple, content age specific, Explanations simple, content age specific, pace pace

• Literacy and language, and sensory, needsLiteracy and language, and sensory, needs

Recommendations: Good Recommendations: Good practice practice

• Implementation of ‘what works in adults’Implementation of ‘what works in adults’• Adaptation - addiction and old age Adaptation - addiction and old age

servicesservices• Evidence base for the older age group: Evidence base for the older age group:

length, dosage, type of interventionlength, dosage, type of intervention• Development of protocols and care plansDevelopment of protocols and care plans• InnovationInnovation• Flexible, adaptive, optimistic and long Flexible, adaptive, optimistic and long

term term

Recommendations: Recommendations: AssessmentAssessment

• A thorough, ongoing assessment A thorough, ongoing assessment which includes a comprehensive which includes a comprehensive history history

• Many tools for screening, assessment Many tools for screening, assessment and monitoring outcome but for and monitoring outcome but for adultsadults

• Neurocognitive impairment Neurocognitive impairment • Semi-structured interviews increase Semi-structured interviews increase

identification identification • Severity of substance use, misuse and Severity of substance use, misuse and

dependence. dependence. • Substance use and mental disordersSubstance use and mental disorders

Assessing elderly patients Assessing elderly patients (Parker, Hospital Doctor 26 4 07, and Crome(Parker, Hospital Doctor 26 4 07, and Crome

personal communication!)personal communication!)• Guard against clinical ageism: not an Guard against clinical ageism: not an

indicator of ability to function, benefit from indicator of ability to function, benefit from treatment, quality of lifetreatment, quality of life

• Comprehensive geriatric assessment is key Comprehensive geriatric assessment is key to effective practiceto effective practice

• Functional assessment is a useful clinical Functional assessment is a useful clinical tooltool

• Geriatric medicine oriented towards Geriatric medicine oriented towards problems (but must not neglect diagnosis) problems (but must not neglect diagnosis)

• Don’t write ‘poor’ historian: consider reasons Don’t write ‘poor’ historian: consider reasons for poor history eg hearing aid, confusionfor poor history eg hearing aid, confusion

RecommendationsRecommendations

• Social admission is a myth and not a Social admission is a myth and not a medical diagnosismedical diagnosis

• Understand ‘geriatric giants’: falls, Understand ‘geriatric giants’: falls, confusion, decreasing mobility, confusion, decreasing mobility, incontinence, (iatrogenesis, frailty)incontinence, (iatrogenesis, frailty)

• Manage underlying causeManage underlying cause• Learn to recognise deliriumLearn to recognise delirium• Drug therapy is often the cause of Drug therapy is often the cause of

symptomssymptoms

InstrumentsInstruments• G-MAST - Geriatric version of MAST >5 G-MAST - Geriatric version of MAST >5

positive positive {{MAST, SMAST, B-MAST (Michigan MAST, SMAST, B-MAST (Michigan Alcohol Screening Test)}Alcohol Screening Test)}

• SMAST-G shorter version of the G-MASTSMAST-G shorter version of the G-MAST• CAGE - 4 questions >2 positive (Hinkin CAGE - 4 questions >2 positive (Hinkin

2002)2002)• Alcohol related problems survey for older Alcohol related problems survey for older

people (ARPS) and Short ARPS (shARPS)people (ARPS) and Short ARPS (shARPS)• AUDIT (Alcohol use disorders test) or AUDIT -5 AUDIT (Alcohol use disorders test) or AUDIT -5

(Philpot et al 2003) (Philpot et al 2003)

• MAST-G and CAGE most appropriate MAST-G and CAGE most appropriate Beullens et al Beullens et al

20042004

• NO VALIDATED INSTRUMENTS FOR DRUG NO VALIDATED INSTRUMENTS FOR DRUG MISUSEMISUSE

Recommendations: Critical Recommendations: Critical issues in treatment issues in treatment

What is an appropriate treatment What is an appropriate treatment goalgoal?? What is What is motivationmotivation for psychological change? for psychological change? Regularity and credibility of Regularity and credibility of medical medical advice? advice? How How appropriateappropriate are techniques for are techniques for

assessment, advice, assistance? IT, telephone, assessment, advice, assistance? IT, telephone, larger printlarger print

Ask Assess Advise Assist Prescribe Arrange!Ask Assess Advise Assist Prescribe Arrange! AdequateAdequate fluids, eating as soon as possible fluids, eating as soon as possible Anti-epileptics and anti-emetics – rarely Anti-epileptics and anti-emetics – rarely

requiredrequired

NICE guidelines and NICE guidelines and othersothers

• Psychosocial interventionsPsychosocial interventions• Opioid detoxificationOpioid detoxification• Methadone and burprenorphineMethadone and burprenorphine• NaltrexoneNaltrexone• Community interventions in vulnerable substance Community interventions in vulnerable substance

misusersmisusers• Department of Health ‘Orange’ book 2007Department of Health ‘Orange’ book 2007• SIGN guidelines – ScotlandSIGN guidelines – Scotland

By and large comorbidity and vulnerable age By and large comorbidity and vulnerable age groups are groups are

excludedexcluded

Pharmacological Pharmacological treatmenttreatment

MedicationMedication LicensedLicensed Age limitsAge limits Specific old age

DiazepamDiazepam Alcohol Alcohol withdrawalwithdrawal

Not in Not in childrenchildren

<half adult doseIn anxiety

Chlordiaze-Chlordiaze-poxidepoxide

AlcoholAlcohol

withdrawalwithdrawalNot in Not in childrenchildren

< half adult dose for anxiety

DisulfiramDisulfiram Alcohol Alcohol deterrentdeterrent

Not in Not in childrenchildren

None

MethadoneMethadone Opiate Opiate addictionaddiction

Not in Not in childrenchildren

Caution

SubutexSubutex Opiate Opiate addictionaddiction

>16 years>16 years None

LofexidineLofexidine Opiate Opiate detox’ndetox’n

Not in Not in childrenchildren

Caution

NRTNRT Nicotine Nicotine withdrawalwithdrawal

> 18 years> 18 years None

BupropionBupropion Smoking Smoking cessationcessation

> 18 years> 18 years Caution

Pharmacological Pharmacological treatment optionstreatment options

• Drugs not investigated/licensed for over Drugs not investigated/licensed for over 65s65s

• Benzodiazepines – caution due to Benzodiazepines – caution due to accumulation but need to give enough to accumulation but need to give enough to cope with withdrawalcope with withdrawal

• Acamprosate, disulfiram and naltrexone Acamprosate, disulfiram and naltrexone with utmost cautionwith utmost caution

• Methadone and buprenorphine supervisedMethadone and buprenorphine supervised• Nicotine replacement and bupropion if not Nicotine replacement and bupropion if not

C/AC/A

OUTCOME OUTCOME STUDIES OLDER STUDIES OLDER

PEOPLEPEOPLE

Do older people recover?Do older people recover?

Systematic Review of Systematic Review of Treatment for Older Treatment for Older

People Substance People Substance ProblemsProblems

Ishbel Moy Martin Frisher

Peter CromeIlana Crome

School of Medicine and School of Pharmacy

Keele University

Search StrategySearch Strategy

• Search conducted May/June 2007, information Search conducted May/June 2007, information from each study collated and tabulated, report from each study collated and tabulated, report written June/July 2007written June/July 2007

• PubMed, The Cochrane Library, MEDLINE, Project PubMed, The Cochrane Library, MEDLINE, Project CORK, and EMBASE searched up to January 2007CORK, and EMBASE searched up to January 2007

• Studies generated from expert consensus papers or Studies generated from expert consensus papers or advisorsadvisors

• KKeywords included: elderly; older people; eywords included: elderly; older people; addiction; substance misuse; substance abuse; addiction; substance misuse; substance abuse; treatment; alcohol; nicotine; smoking cessation; treatment; alcohol; nicotine; smoking cessation; prescription medications; benzodiazepines; illegal prescription medications; benzodiazepines; illegal drugs; illicit drugsdrugs; illicit drugs

Inclusion CriteriaInclusion Criteria

1 Older defined as 50+ years.1 Older defined as 50+ years.2 Substances:2 Substances:

- alcohol- alcohol- nicotine- nicotine- prescription medications- prescription medications- illicit drugs- illicit drugs

3 Trials focussing on ‘older’ people specifically 3 Trials focussing on ‘older’ people specifically 4 Trials comparing older with younger 4 Trials comparing older with younger 5 Pharmacological and psychological 5 Pharmacological and psychological

treatments for addictiontreatments for addiction

Studies IncludedStudies Included

• 2500 titles generated.2500 titles generated.• 50 studies thought to be appropriate and full 50 studies thought to be appropriate and full

articles obtained.articles obtained.• 16 studies fulfilled inclusion criteria:16 studies fulfilled inclusion criteria:

- 9 on alcohol misuse- 9 on alcohol misuse

- 2 on treatment of alcohol and drug misuse - 2 on treatment of alcohol and drug misuse (grouped with alcohol misuse for analysis)(grouped with alcohol misuse for analysis)

- 3 on smoking cessation- 3 on smoking cessation

- 1 on methadone maintenance- 1 on methadone maintenance

- 1 on prescription medications- 1 on prescription medications

Evidence - Review of 16 Evidence - Review of 16 studies on older substance studies on older substance

misusersmisusers• Current evidence based guidance does Current evidence based guidance does

not include over 50snot include over 50s• Mainly alcohol (11); smoking (3); Mainly alcohol (11); smoking (3);

opiates (1) and prescription drugs (1) opiates (1) and prescription drugs (1) in over 50sin over 50s

• 2 studies in the UK 2 studies in the UK • Some in services for older people; Some in services for older people;

some in mixed age servicessome in mixed age services• Almost all treatments were variety of Almost all treatments were variety of

psychological interventions psychological interventions

ResultsResults• Time periodTime period: 1984-2001; 14 of these after : 1984-2001; 14 of these after

1990.1990.

• CountryCountry: 13 in US, 2 in UK, 1 in Canada.: 13 in US, 2 in UK, 1 in Canada.

• Settings:Settings: 5 studies conducted in primary 5 studies conducted in primary care, 4 in outpatient setting, 1 inpatientcare, 4 in outpatient setting, 1 inpatient

• Sample sizeSample size:: 24 to 3,622; some of the 24 to 3,622; some of the larger studies had a relatively small larger studies had a relatively small proportion of adults in ‘older’ age range.proportion of adults in ‘older’ age range.

• Demographic informationDemographic information::- Age cut-off for ‘older’ varied, from 50+ - Age cut-off for ‘older’ varied, from 50+

years and years and 65 + years.65 + years.

- Majority of participants in 14 studies - Majority of participants in 14 studies were male; were male; other 2 were 93% other 2 were 93% and 100% and 100% female.female.

- 6 studies >70% Caucasian participants.- 6 studies >70% Caucasian participants.

• Ethics approval:Ethics approval: 6 studies described 6 studies described ethical approval or exemption.ethical approval or exemption.

ResultsResults

• Measures:Measures:

- - e.g. baseline: e.g. baseline: quantity/frequency; time-line follow-quantity/frequency; time-line follow-back; addiction severity index (ASI); back; addiction severity index (ASI); Beck Depression Inventory; physical Beck Depression Inventory; physical and and psychiatric problems.psychiatric problems.

- e.g. outcome: ASI; abstinence; - e.g. outcome: ASI; abstinence; drinks/day; health status; drinks/day; health status; formal/informal aftercareformal/informal aftercare

ResultsResultsDesignDesign: : 5 studies contained a 5 studies contained a

control group.control group.

Programmes:Programmes:• Elder-specific programs or examined Elder-specific programs or examined

older patients in 7 studiesolder patients in 7 studies

• Older patients treated in adult addiction Older patients treated in adult addiction programs and compared with younger programs and compared with younger age groups in 8 studies age groups in 8 studies

• 1 compared outcomes of older adults in 1 compared outcomes of older adults in both elder-specific and adult addiction both elder-specific and adult addiction programs.programs.

Overview of Study Overview of Study Findings - AlcoholFindings - Alcohol

Number of patients who achieve their follow-Number of patients who achieve their follow-up goal is at least comparable to that of up goal is at least comparable to that of other populations.other populations.

..Those patients in elder-specific treatment Those patients in elder-specific treatment

appear to improve across a wide variety of appear to improve across a wide variety of outcome domains.outcome domains.

Brief Advice and Motivational Enhancement Brief Advice and Motivational Enhancement are equally successful for both older and are equally successful for both older and adult populations.adult populations.

Overview of Study Overview of Study Findings - AlcoholFindings - Alcohol

Potential for good outcomes in those older people Potential for good outcomes in those older people who seek treatment; possible they may have who seek treatment; possible they may have achieved even better outcomes in an elder-achieved even better outcomes in an elder-specific program.specific program.

Both older men and women are capable of Both older men and women are capable of achieving abstinence if given access to alcohol achieving abstinence if given access to alcohol abuse programs.abuse programs.

Value in treating older adults and that they are Value in treating older adults and that they are able to respond positively to treatment, but that able to respond positively to treatment, but that there was a lack of knowledge on long-term there was a lack of knowledge on long-term management. management.

Overview of Study Findings – Overview of Study Findings – Smoking, Heroin, Smoking, Heroin,

Prescription MedicationsPrescription MedicationsSmoking:Intervention with the nurse practitioner led to a

decrease in smoking.Older smokers appeared to benefit as much as younger

smokers from brief office-based counselling. .Heroin:Older patients might have fewer problems and do very

well in treatment for heroin dependence.

Prescription Drugs:Participation was associated with a significant

reduction in benzodiazepine, narcotic and overall prescription use; the reduction in health care utilisation observed may translate to savings in health care costs.

THE WAY FORWARD – THE WAY FORWARD – the ABC…… the ABC……

• Advocacy, attitudes• Better, appropriate

treatment• Care, risk, resilience,

recovery• Dignity, integrity, quality• Enthusiasm for evidence• Further research • Generational training,

partnership working• High priority: value

older people…………

Thanks to colleaguesThanks to colleagues

• Dr Roger BloorDr Roger Bloor• Prof Peter CromeProf Peter Crome• Drs Ishbel Moy & Harvinder SidhuDrs Ishbel Moy & Harvinder Sidhu• And many other collaborators…sorry And many other collaborators…sorry

not to mention by namenot to mention by name