public health aspects of addiction in older people

Dr Tony RaoConsultant Old Age Psychiatrist

Visiting ResearcherSouth London and Maudsley NHS Foundation Trust

Institute of Psychiatry, Psychology and Neuroscience

Public Health Aspects of Addiction

in Older People

LEARNING OBJECTIVES

1. To understand the contribution of the disease burden from substance use in older people

2. To be aware of the association between substance misuse and physical, psychological & social factors in older people

3. To be familiar with trends in substance misuse in older people

4. To improve knowledge of public health interventions for substance misuse

“Middle age is also the time when social drinking merges insensibly with the early manifestations of chronic alcoholism.

It may be many months before the store of gin bottles is discovered in the kitchen cupboard

In any event, in no case with a decline in memory for recent events, an unexplained attack of delirium or hallucinosis or a change in personality, should the possibility of alcoholism fail to be considered”

Professor Sir Martin Roth

Journal of the College of General Practice 1964

“It would be too optimistic to suppose that the relative under-representation of subjects in the older age groups among clients of information centres is just explained by older people having generally got the treatment they required or having reverted to normal drinking...it seems likely that this finding is in part a hint of the diminished life expectancy of the alcoholic”

Professor Griffith Edwards BMJ 1967

• Tobacco – great impact

• Alcohol – great impact

• Cannabis – moderate impact

• Cocaine – increasing impact

• Illicit drugs-heroin, amphetamines – lower impact

• Prescription drugs – impact not known

• Over the counter drugs – impact not known

SUBSTANCES AND OLDER PEOPLE

1. Rising older population

2. Higher Substance Misuse related mortality rates

in older vs younger people

3. High rates of mental health problems in older

people

4. Older people show complex patterns and

combinations of substance use

5. In Europe, numbers will double in the next 2

decades, and in the USA, set to treble

NATURE AND EXTENT OF THE PROBLEM 014

7.8

16

8.6

17

10.2

19

12

22

0

5

10

15

20

25

Population of England (million) % of Total

2001201120212031

PROJECTED POPULATION OF ENGLAND

IN 65+ AGE GROUP 2001-2031

1986

2011

The Baby Boomers

Turn 65

Risk factors vary by deprivation quintile in 50–69 year-olds

Most deprived quintile: Tobacco 20% (Leading risk factor)Alcohol and drug use ranking fifth 7.1%

Least deprived quintile:Tobacco 11% (High BMI leading risk factor)Alcohol and drug use ranking sixth 4.6%

BURDEN OF DISEASE IN ENGLAND ATTRIBUTABLE TO RISK FACTORS - 2013 (Department of Health, 2015)

• Liver disease

• Hypertension

• Delirium

• Falls

• Cognitive Impairment

• Depression

• Suicide

Associated Disorders

• Older people at increased risk of adverse effects of

substance use, even at low levels

• Increased risk of substance use disorders from

prescribed and over the counter medication

• Physical health problems from prescription of hypnotics,

anxiolytics and analgesics for sleep, anxiety and pain

• Psychiatric problems related to substance use disorders

e.g. delirium, intoxication, withdrawal syndromes,

anxiety, depression, cognitive impairment

• Psychosocial factors e.g. bereavement, retirement,

boredom, loneliness, homelessness, depression

associated with onset alcohol use disorders

Precipitants and complications

Alcohol

Conceptual causal model of alcohol consumption and health outcomesGilmore et al. (2016)

Percentage drinking over lower risk limits in England

Copyright © 2018, Re-used with the permission of NHS Digital. All rights reserved

0

5

10

15

20

25

30

35

16-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years 75+ years All adults

2013 2014 2015 2016 2017 2018


0

5000

10000

15000

20000

25000

30000

35000

40000

2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19

3783739512

3752836563

3381932409

36593

22565

25288 2603427870 27110 26991

30642

Alcohol-specific admissions in England for mental and behavioural disorders

15-49 50+

Copyright © 2019 Re-used with the permission of NHS Digital. All rights reserved

0

1000

2000

3000

4000

5000

6000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

2219 2281 23362500 2404 2511 2503 2465 2450

2210 2207 2194 2097 2118 22052069

4034 41054268

44374555

4836

44074605

4729

44594584

4808 4909

5208

5492 5482

Alcohol Specific Deaths in the UK: 2003-2018

15-49 50+

Percentage change in numbers accessing addiction treatment services in England 2005/06 to 2018/19


-500

0

500

1000

1500

2000

2500

18-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Total

Both opiate and crack cocaine Crack cocaine (not opiate) Cannabis Cocaine Alcohol

Other substances

Proportion who smoke cigarettes in the UK 1974-2013

8.1

1.41.0

0.1 0.1

7.7

7.1

1.8 1.7

0.2

10.4

6.5

1.5

0.8

1.4

9.6

5.2

2.2

1.6

1.0

0.00.51.01.52.02.53.03.54.04.55.05.56.06.57.07.58.08.59.09.5

10.010.511.0

16-24 25-34 35-44 45-54 55-64

Percentage of men with drug dependencefrom Adult Psychiatric Morbidity Survey

1993

2000

2007

2014

2.20%

1.50%

1.20%

3.20%

3.00% 3.00%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

Opioids Tranquilizers Stimulants

Non-medical prescription lifetime drug use People aged 50 and over Schepis & McCabe 2016

2002–2003

2012–2013

Potentially Inappopriate Prescribing in Europe based on 57 ScreeningsOnatade et al 2013

Drug group % of studies reporting item in their top 10

Anxiolytics 81

Hypnotics and sedatives 43

Population strategies to prevent smoking and alcohol misuse

Public places

Public roads

Price

Public Education

Promotion

Point of sale

Product labelling

Packaging

Probity

From: Changing risk behaviours and promoting cognitive health in older adultsAn evidence-based resource for local authorities and commissioners (Lafortune et al 2016)

2017-2018

Current areas for future research

Prescription drug misuse

Over the counter medication misuse

Dual Diagnosis

Gabapentinoid drugs

“Medicinal” cannabis

Novel psychoactive substances

New cohort effects

public health aspects of addiction in older people

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