Substance misuse problems may be more difficult to identify in older people, so screening and assessment should be carried out to prevent further harm.
Citation: Rassool GH (2012) Substance misuse in older people 2: identifying and treating substance misuse. Nursing Times; 108: Online issue.
Author: G Hussein Rassool is independent consultant and visiting professor of addiction and mental health, Universidade de São Paulo and Universidade de Minas Gerais, Brazil, and director, Inter Cultural Therapy Centre, Mauritius.
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The ageing process is often associated with a range of social, psychological and health-related problems. Bereavement, social isolation and lack of social support may lead to social problems. Psychological problems may include depression, anxiety, loneliness, memory problems, confusion, cognitive impairment and early dementia. Physical problems may include lack of mobility, accidents and self-care deficits.
Evidence suggests older drug users report high levels of unemployment and social isolation, and present with chronic physical and psychological consequences of long-term substance misuse (European Monitoring Centre for Drugs and Drug Addiction, 2010). Many older people with substance misuse problems are simply continuing a pattern of behaviour or addiction that began earlier in their lives or have a family history of alcohol or drug addiction.
Problems of identification
The physical, social, psychological and legal problems associated with substance misuse in older people mean they are likely to have regular contact with health and social care services. However, early recognition of substance misuse in this group is more difficult than in younger people.
The nature and pattern of older people’s consumption make the problem less obvious - they are less likely to be involved with the criminal justice system, get arrested, get into arguments or miss work because of drug-taking or drinking. They are also likely to consume substances at home. Benshoff et al (2003) argued that the largest factor contributing to substance misuse in older people is family, caregiver and clinician complicity in the addiction process. In addition, significant others, primary care staff and other healthcare services may fail to identify substance misuse. The reasons for health professionals’ failure to recognise this in older people includes lack of educational preparation and lack of awareness of substance misuse in this group.
Recognising signs and symptoms
Certain behaviours may act as “warning flags” that signal substance misuse in older people; these include frequent intoxication, an established pattern of heavy drinking or drug-taking, and drinking and drug-taking in dangerous situations such as when driving. Table 1 presents the signs and symptoms that may indicate a substance misuse problem.
Screening is a brief process that aims to determine whether an individual has a drug and/or alcohol problem, health-related problems or is showing signs of risk behaviours. Substance misusers may present in accident and emergency departments with overdose, self-harm, lost prescriptions, withdrawal seizures, delirium tremens and withdrawal syndrome.
The CAGE questionnaire on alcohol consumption is the simplest screening method. It concentrates on the consequences, rather than the quantity or frequency, of alcohol use, and its four questions can easily be incorporated in the routine assessment process:
- Have you ever felt that you should Cut down your drinking?
- Have people Annoyed you by criticising your drinking?
- Have you ever felt bad or Guilty about your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?
Two or more positive responses identify problem drinkers. This screening instrument also appears to have adequate validity for detecting alcohol misuse/dependence in medical and surgical inpatients, psychiatric inpatients and ambulatory medical patients (Dhalla and Kopec, 2006). It can be used to initiate discussions about substance use in order to promote heath education and harm-reduction strategies.
Other traditional screening instruments have been used with older people including the Michigan Alcohol Screening Test and the Alcohol Use Disorders Identification Test. The Short Michigan Alcoholism Screening Test - Geriatric Version is often used in outpatient settings to detect at-risk alcohol use, alcohol misuse or alcohol disorders in older people.
No screening instrument provides sufficient data to make a clinical diagnosis, although it may help to determine whether it is necessary to recommend a more comprehensive assessment by a specialist addiction nurse. This involves a complete assessment including clients’ readiness to engage in treatment, risk behaviours and the urgency to access treatment. Subsequently, a client might be offered services or referred to another specialist service.
When undertaking screening for alcohol and drug misuse, it is also important to be culturally competent in dealing with older people for whom the use of alcohol (and drugs) is forbidden due to religious sanctions.
A comprehensive assessment to identify alcohol and/or drug misuse includes physical, social, psychological and spiritual needs. As there is a strong relationship between substance misuse, the criminal justice system and sexual behaviours, the subject should be discussed in relation to patients’ needs and problems. Assessment should include a full history (including a collateral history from a suitable informant), mental-state examination, physical examination, social assessment, legal problems (if any) and investigations.
Taking a drug and alcohol history involves a detailed assessment of the current presentation of an individual’s drug and alcohol pattern of use. One of the initial tasks is to discern patients’ views of their drug and/or alcohol consumption. The assessment should then focus on the current pattern of substance misuse, the type of drug used, quantities, level of dependence, risk behaviours, associated problems, source of help, source of access to psychoactive substance(s) and periods of abstinence and relapse. To ascertain the level of dependency, it is important to ask about experiences of withdrawal symptoms or any medical complications. Table 2 gives an outline of the assessment.
In relation to sexual issues, it is important to assess the sexual risks of those who misuse psychoactive substances because evidence suggests that although people are aware of the risk of sexually transmitted diseases, they are uncomfortable seeking health information about them (Morton et al, 2011). Health education and harm reduction also form part of the assessment process.
A social assessment may also be needed (which may need the input of a social worker) and includes:
- Recent and impending life changes;
- Quality of significant relationships and health of partner;
- Current and future living environment;
- Current caregiver network including its deficiencies and potential;
- Services needed and received.
Older adults who misuse substances may have complex or multiple needs that are often difficult to assess and may warrant further investigation. There are clear associations between substance misuse (particularly alcohol) and a variety of physical conditions, including liver disease, hypertension, diabetes, falls, cognitive changes, depression, self-harm and incontinence (Royal College of Psychiatrists, 2011); mental-health problems are also associated with substance misuse. Indicators for further assessment may include:
- Physical problems;
- Mental-health problems;
- Social problems;
- Legal problems (if appropriate);
- Symptoms of withdrawal;
- High tolerance of psychoactive substances;
- Misuse of prescription and over-the-counter drugs;
- Previous detoxification and/or rehabilitation;
- Self-medication of psychoactive substances for alleviating mental-health problems.
Clinical examination (physical and mental) should be part of the comprehensive assessment; additional collateral data and laboratory tests would provide confirmation of the presence or absence of substance use. Assessment should include determining the potential for sudden withdrawal from alcohol or drugs, which can be life-threatening in older adults.
The government’s models of care for alcohol and drug misuse provide best-practice guidance for local health organisations in delivering a planned and integrated treatment system for substance misusers (Department of Health, 2006; National Treatment Agency for Substance Misuse, 2006). Alcohol misusers need specialist treatment from community alcohol teams, inpatient detoxification units and structured day or residential programmes. Self-help groups such as Alcoholics Anony- mous and other voluntary agencies may also play an important role in managing care and treatment interventions.
The choice of setting in each case will depend on the range of accompanying physical, psychological or social problems, including risks posed to the drinker and risks to others as a result of the drinker’s behaviour (DH, 2006; NTA, 2006). Problem drinkers making contact with health professionals either in primary care or at specialist units are usually offered a detoxification programme as a prelude to further psychosocial interventions.
Treating drug addiction focuses on three main components: dealing with detoxification and withdrawal effects; maintenance (also known as substitution or harm-reduction therapies); and abstinence. Drug treatment may include drug detoxification, methadone maintenance therapy, motivational interviewing and counselling or other cognitive behavioural therapies, marital and family therapy, relapse prevention and the 12-steps approach used by organisations such as Alcoholics Anonymous. In addition, self-help groups such as Narcotics Anonymous and Cocaine Anonymous are also part of the package of care. Both pharmacological and psychosocial interventions are used, often complemented by educational and vocational rehabilitation.
Older people may be severely dependent on alcohol or other psychoactive substances. Those with a high potential for problems in withdrawal or who have other medical or psychiatric problems may need to be hospitalised before an outpatient treatment and management programme can begin. Patients are initially weaned off alcohol or drugs, under nursing and medical supervision, while hospitalised.
It is part of the nurse’s role to screen or take a drug and alcohol history for all older people attending primary care. However, it is common for no drug or alcohol history to be included in the initial assessment unless it is clear from observed signs that patients have a problem (Vastag, 2003).
It is important to restate questions or make sure older people have a clear understanding of the issues surrounding alcohol and drug misuse. It is vital to engage them by conducting the assessment or screening in a sensitive, non-judgemental way and offering reassurance about confidentiality.
Generalist healthcare workers (for example, nurses in general hospital settings or primary healthcare workers) are primarily concerned with the interim, brief history-taking of alcohol and other substance misuse problems rather than a full or specialist assessment. The latter is usually carried out by an addiction nurse or other health and social care professional as part of a multidisciplinary assessment of needs and subsequent specialist interventions (Rassool, 1998).
Often, when practitioners take an alcohol or drug history, they fail to take into consideration older adults’ varying levels of safe consumption, their increased vulnerability to the effects of alcohol or the problems associated with the high prevalence of medication use in this age group (Barry et al, 2002).
Some of the challenges that nurses and other health professionals face are that older adults are often uncomfortable discussing alcohol consumption; this is especially true of women and may be due to the stigma attached to substance misuse or because it is considered unacceptable in many cultural and religious groups. Older people may deny or minimise the amount of alcohol they consume, making it hard to obtain an accurate assessment.
Support in detoxification
For those older adults needing detoxification, preparation is important to build their confidence and maximise the benefits from the detoxification episode (Raistrick et al, 2006). Patients need a non-stimulating and non-threatening environment, and low lighting at night will help reduce perceptual disturbances.
While detoxification can be an extremely physical process, there are a number of psychological elements that nurses are skilled at observing and managing, including hallucinations, delirium, altered mental states, hyper-vigilance, anxiety, paranoia, depression, tactile hallucinations and levels of risk (Moore, 2006).
The principles of managing alcohol detoxification include: monitoring dehydration; blood pressure; dietary intake; orientation to time, place and person; and sleep. The key aspects of care on which nurses should focus are:
- Promoting client safety;
- Maintaining physiological stability during the withdrawal phase;
- Meeting physical and psychological needs;
- Providing appropriate referral and follow-up.
Older adults should be monitored continually for signs and symptoms of alcohol withdrawal throughout detoxification, especially as medication dosages are adjusted.
Nurses are well placed to deliver brief interventions. These, as well as screening, can be delivered in primary care or hospital settings; they are among the most effective and cost-effective prevention services (Solberg et al, 2008). Brief interventions aim to motivate those at risk to change their alcohol (or drug) use behaviours (Babor and Higgins-Biddle, 2001).
Brief interventions comprise short advice or several short (lasting 15-30 minutes) counselling sessions and are designed to be conducted by non-specialist or generalist health professionals. The acronym FRAMES summarises the elements of effective brief interventions: Feedback, Responsibility, Advice, Menu, Empathy and Self-efficacy (Bien et al, 1993). For a comprehensive account of effective brief interventions see Rassool (2010).
The NICE (2007) guideline on psycho-social interventions for drug misuse recommended that opportunistic brief interventions should:
- Normally consist of two sessions, each lasting 10-45 minutes;
- Explore ambivalence about drug use and possible treatment (with the aim of increasing motivation to change behaviour), and provide non-judgemental feedback.
Nurses should also be cognisant with health education and harm-reduction strategies. Every encounter with a patient affords an opportunity to provide information about prevention and harm reduction in relation to tobacco smoking, alcohol use, psychoactive drug use and sexual health. Nurses have a role to play in both reducing the risk of patients engaging in substance misuse and reducing the harm associated with it. In addition, the aim is to reduce the number of drug-related deaths and blood-borne virus infections.
For various reasons alcohol and drug misuse among older people has not been viewed as a serious or widespread problem. Nurses need to be aware that dependence on alcohol or drugs in older people can be mistaken for or masked by a number of physical or psychiatric conditions common in this group, such as depression, insomnia, poor nutrition and frequent falls.
Current service provision for older adults who misuse substances has been regarded as inappropriate in meeting their complex needs. The aim is to provide an accessible and flexible treatment setting that can respond to their unique needs and may require involvement from primary healthcare teams and families.
While these needs may include managing and treating problems of substance misuse, they are also likely to include addressing other physical, social and psychological issues. The success of any intervention with older people who misuse substances depends on use of a coordinated approach with health and social care agencies.
The role of nurses and other health professionals is to support, educate, prevent and provide care. Nurses should therefore routinely discuss substance use with older patients. However, if nurses and other health and social care professionals do not receive adequate education and training, current approaches aimed at dealing with this problem in older people are bound to fail.
- It is more difficult to recognise early signs of substance misuse in older people than in younger people
- Certain behaviours can act as “warning flags” of substance misuse in older people
- A comprehensive assessment includes assessing a patient’s physical, social, psychological and spiritual needs
- Nurses should screen or take a drug and alcohol history for all older people attending primary care
- Screening and brief interventions can be delivered by nurses in primary care or hospital settings
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