Substance use in older adults: different ways
of illuminating its prevalence and use
A look at data from recent POWH and SESLHD D&A
studies
Thanks to Nicholas Lintzeris and Brian Draper What I’ll cover… and the highlights
l  1. Age:
–  What is old anyway?
–  An aging population
l  2. Which substances do older adults use?
–  Misuse: Alcohol, BDZ, and Cannabis
–  Use: High proportion of prescription BDZ and opiates
–  Substance misuse is poorly identified and addressed in clinical
practice
l  3.Profile of older adults in D&A treatment setting
–  High use of services, high rates of depression, physical comorbidities
and social isolation
1. Age:
l  What is old anyway? ….
l  An aging population
l  There is no single age ‘cut-off’ that captures the different
older populations with substance misuse disorders
§  Aged Care Services
75+
§  Mental Health Services
65+
§  Drug & Alcohol Services
50+
§  General Public
??
2. Which substances do older adults use?
Data:
General Population: Australian Household Data 2010
Patients using POW health services: (Draper et al)
General
population
Health
Services
D&A
Treatment
Data from General Population:
Australian Household Survey Data
2010
General
population
Health Services
D&A Treatment
Older people have lower rates of risky alcohol use
2010 National Drug Household Survey
60.0
50.0
40.0
Is decline due to aging or a cohort effect?
%Short term risk
30.0
% Long term risky and
high risk
20.0
10.0
0.0
20-29 30-39 40-49 50-59 60-69
70+
Short term risk >4 St Drinks (10gm) on single occasion
Long term high risk drinking > 2 St drinks (10gm) / day
… and lower rates of Illicit drug use
National Household Surveys 1995-2010
25
20
15
Total adult
40-49
%
50-59
10
60+
? Cohort effect
5
0
1995
1998
2001
2004
2007
2010
… but high and rising rates of non-medical
pharmaceutical use
National Household Surveys 1995-2010
7
6
5
Total adult
4
40-49
%
3
50-59
60+
2
1
0
1995
1998
2001
2004
2007
2010
… and the older the greater this is
Substance
Age
12
months
Lifetime
Non-medical
pharmaceutical
use
65-74
>75
3.6%
6.1%
4.9%
7.3%
Alcohol use
disorder
65-85
11.7%
1
2
THESE DATA DO NOT INCLUDE PEOPLE IN HOSPITAL
1. 2010 National Household Survey
2. 2007 National Survey of Mental Health and Wellbeing
Data from patients >60 using
POW health services
Prof Brian Draper , Adrienne Withall ,
A/Prof Nicholas Lintzeris
General
population
Health Services
D&A Treatment
Health users study(Draper et al, MHDAO grant)
l  Screening of patients aged 60+ attending aged care facilities
l  Methods:
–  Screening for alcohol use disorder
–  (AUDIT-C positive (≥5 male, ≥3 female)) or any other substance use
past 3/12 (ASSIST) further assessed
–  excluded tobacco, only prescribed opiates/ BZDs
–  If +ve à Medical chart reviews & qualitative interviews
l  229 of 942 POWH included (83% of eligible patients)
–  667 excluded (70.8 %)
–  cognitive impairment (MMSE<24), Non English speaking, acute
illness, refused to participate (42)
... And its conclusions
l  Patterns of substance use in aged care health services sample
was greater than household survey data
–  10-15% at mod – high risk of substance use disorder: alcohol
& non-medical use prescription drugs
–  High levels prescription medication use: ~30% BZDs (2/3rds
daily use); ~20% opioids (80% daily)
l  Substance use disorder poorly identified & managed
l  note .... Baby boomers haven’t arrived yet in this sample
… high rates of recent Rx sedatives/
opiates
Total (N=229)
Male (N=83)
Female (N=146)
N
%
N
%
N
%
p
Tobacco
13
5.7
5
6.0
8
5.5
0.87
Alcohol
130
56.8
57
68.7
73
50.0
<.01
Cannabis
Cocaine/Amphetamines
Inhalants/ Hallucinogens
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
Sedatives (as prescribed)
63
27.5
21
25.3
42
28.8
.57
Sedatives (not as prescribed)
8
3.5
2
2.4
6
4.1
.71
Opioids (as prescribed)
39
17
15
18.1
24
16.4
.86
Opioids (not as prescribed)
3
1.3
2
2.4
1
0.7
.30
0f the 12% screened +ve for ETOH use
disorder - 2/3 at significant risk
Low Risk
Medium
Risk
High Risk
Alcohol (n=37)
14 (38%)
21 (57%)
2 (5%)
BZD (n=8)
1 (13%)
5 (63%)
2 (25%)
Opioids (n=2)
1
0
1
Total (n=43)
15 (35%)
23 (53%)
5 (12%)
+ves for substance misuse not well
identified in routine practice
§  Alcohol
-  62% had any alcohol history documented
-  22% had concerns documented by medical staff; usually
when presentation directly related to use (e.g. falls)
-  15% had management plans recorded
-  6% D&A service involvement
§  Pharmaceuticals
•  38% of screen positive BZD misuse identified, 25% had
management plan, none referred to D&A
•  The two opioid misusers were identified as suffering
chronic pain & referred to the pain clinic
Patients screening +ve for substance use problem:
their perspective
§  Most don’t think they have a substance abuse issue.
§  Few had been told to ‘cut down’ on drinking by GP, family or
friends; others commented that their GP knew of their alcohol use
and hadn’t recommended any change. Others reported not telling
their doctor –
‘I don’t tell my doctor how many drinks I have, he doesn’t ask
specifically. It’s none of his business’
§  Most had never sought help
§  only 1 person had received help for alcohol and 1 for prescription
drug use (GP stopped prescribing)
§  Many did not know what D&A services were available or how to get
help.
3. Profile of older adults in D&A treatment
setting
Data: patients >50 attending SESLHD D&A services (Lintzeris et al)
l  Using alcohol, BZDs and cannabis rather than heroin, ATS, cocaine l  Have high rates of physical co-­‐morbidiCes (pain, liver disease, respiratory, sleep), depression and cogniCve problems l  Socially isolated with limited networks l  High rates of health service uClisaCon General
population
Health Services
D&A Treatment
Project Synopsis •  ObservaConal cross-­‐secCon study of paCents aged ≥ 50 yrs aLending D&A treatment services within SESLHD. •  Researcher interview (60-­‐90min) –  Demographics, current treatment –  Recent substance use: ATOP (Ryan et al submiLed), AUDIT –  Health & psychosocial assessment: SF-­‐12, PHQ15, Geriatric Depression Scale (GDS), Lubben Social Network Scale, Bayer ADL Scale, Health Service UClisaCon & FALLS quesConnaires –  CogniCve assessment: ACE-­‐R, MMSE l  20% of D&A outpaCents were >50 –  Recruited 60% of that populaton n=99 mean age 55 OST: Recent substance use (1 mth)
Alcohol, Cannabis, BZD dominate
OST Group (n=69)
100%
90%
80%
22-28 DAYS
70%
15-21 DAYS
8-14 DAYS
60%
1-7 DAYS
50%
0 DAYS
40%
30%
20%
10%
0%
ALCOHOL
HEROIN
OTHER
OPIOIDS
COCAINE
ATS
CANNABIS
BZDS
Alcohol group Recent substance use(1mth)
Alcohol, Cannabis, BZD dominate
Alcohol Group (n=30)
100
90
80
22-28 DAYS
70
%
15-21 DAYS
60
8-14 DAYS
50
1-7 DAYS
0 DAYS
40
30
20
10
0
ALCOHOL
HEROIN
OTHER
OPIOIDS
COCAINE
ATS
CANNABIS
BZDS
>50 D&A setting patients do significantly
worse on all measures
Variable Older DA Overall mean (SD) Mean age 55 Older general pop mean (SD) t (p) ACER-­‐R 82.43 (9.59) 93.70 (4.30) 10.19 (<.001) MMSE 27.68 (2.48) 28.58 (1.34) 5.61 (<.001) Lubben Total 10.36 (5.82) 17.40 (5.50) 12.47 (<.001) PHQ15 8.56 (5.51) 4.50 (4.10) 7.11 (<.001) SF12 Physical 40.55 (11.57) 46.70 (10.60) 4.78 (<.001) SF12 Mental 38.08 (12.87) 53.40 (8.40) 13.16 (<.001) GDS-­‐15 7.38 (1.83) 2.18 (1.90) 25.79 (<.001) BAYER ADL 2.63 (1.62) 1.70 (0.78) 4.14 (<.001) Other source Control group: general populaCon or spouses of paCents M e a n a g e 6 4 . 4 ; N = 6 3 . (
Mioshi et al., 2006) Sydney Memory Study: general populaCon M e a n a g e 7 8 . 5 8 ; N = 8 0 0 . (Reppermund et al., 2011) London sample: general populaCon Mean age 74.5; N = 2598. (
Lubben et al., 2006) General populaCon A g e 5 5 -­‐ 6 4 g r o u p ; N = 8 4 4 . (Kocalevent, Hinz, & Brahler, 2013) South Australian Norms: general populaCon A g e 5 5 -­‐ 6 4 ; N = 2 5 7 . (
Avery, Dal Grande, & Taylor, 2004) South Australian Norms: general populaCon A g e 5 5 -­‐ 6 4 ; N = 2 5 7 . (
Avery, Dal Grande, & Taylor, 2004) Sydney Memory Study: general populaCon M e a n a g e 7 8 . 5 8 ; N = 8 0 0 . (Reppermund et al., 2011) Control parCcipants: outpaCents of geriatric services or spouses of paCents; Mean age 69.25; N = 59. (FolquiLo et al., 2007) InterpretaOon FuncOoning at dement level! MMSE is not much use Isolated Lots of physical comorbidiOes Poor physical funcOon Poor mental health funcOon Depressed DifficulOes managing ADLs …have lots of falls
In the past 12 months
% (N=99)
TRIPPED/SLIPPED 40% FELL TO THE GROUND 57% INJURED BECAUSE OF A FALL 40% NEEDED TO SEEK MEDICAL ATTENTION AFTER A FALL 31% HOW CONFIDENT ARE YOU THAT YOU CAN DO Not Confident 10.1% ALL YOUR DAILY ACTIVITIES WITHOUT Quite Confident 53.5% FALLING? Completely 36.4% MEAN NUMBER FALLS PAST YEAR (SD, RANGE) 2.3 (2.4, 1-­‐6) … ARE SOCIALLY ISOLATED AND ARE NOT
WORKING
N=99
LIVING ARRANGEMENTS
HOME ALONE
63.6%
WITH FAMILY/FRIENDS
26.2%
WITH PARTNER
7.1%
HOSTEL
3.1%
ASSISTANCE IN ADLS
NO ASSISTANCE
91.9%
INFORMAL ASSISTANCE
8.1%
EMPLOYMENT STATUS
EMPLOYED FULL/PART TIME
7.1%
TEMPORARILY UNABLE TO WORK
14.1%
PERMANENTLY UNABLE TO WORK
59.6%
NOT IN THE WORKFORCE
19.2%
…and have high use of expensive services
(in last 4 weeks)
AMBULANCE ED OP HOSPITAL CLINIC ADMISSION TO HOSPITAL GP PSYCHIATRIST OTHER SPECIALIST PSYCHOLOGIST SOCIAL WORKER COUNSELLORS MEDICATIONS MEAN (SD) % SAMPLE 12 13 15 9 57 14 24 16 14 10 1.7 (1.6) l  Which brings us back to what is old for a person using
sunstances?
§  Aged Care Services
75+
§  Mental Health Services
65+
§  Drug & Alcohol Services
50+
§  General Public
??
What was covered
l  1. Age:
–  What is old anyway? … Probably younger than you think
–  An aging population
l  2. Which substances do older adults use?
–  Misuse: Alcohol, BDZ, and Cannabis
–  Less alcohol than younger, but more BDZ and opiates
–  A cohort effect?
–  Use: High proportion of prescription BDZ and opiate
–  Substance misuse is poorly identified and managed in practice
l  3.Profile of older adults in D&A treatment setting
–  Mostly Alcohol, BDZ, Cannabis
–  High use of services, high rates of depression, physical comorbidities
and social isolation