Older people

Elderly 'need alcohol and drug support'

Medical experts have called for new approaches to tackle substance abuse in older adults, several newspapers have reported. According to the Royal College of Psychiatrists, many middle-aged and elderly adults have problems with alcohol, illegal drugs and prescription medication, as well as complex mental health needs that may make the problems worse.

Most newspapers focussed on the report’s proposal to reduce the recommended safe alcohol limit for people over 65. The report recommended cutting it to a maximum of 1.5 units of alcohol a day, equivalent to half a pint of strong beer (5% strength) or a 125ml glass of wine (12% strength). In part, this is due to physical changes as the body ages that make alcohol harder deal with. The current recommended alcohol limits are a maximum of four units a day for men and three units for women.

The report, which has been drawn up by specialists in addiction and substance misuse, says that the misuse of drugs and alcohol by older people is a growing public health problem, which urgently needs to be addressed using measures that focus on the needs of this age group.

Where did the report come from?

The report was published by the Royal College of Psychiatrists. It was produced by a working group composed of specialists in substance addiction and misuse. The report aimed to set out guidance, principles and specific recommendations which, in the view of the College, should be adopted by its members.

What did it find?

The report says that the proportion of older people in the population is increasing rapidly and is projected to rise by 50% between 2001 and 2031. The number of older people with substance misuse problems is also reported to be increasing. The report points out that both alcohol and illicit drugs are among the top ten risk factors for premature death and health problems, and that mortality rates linked to drug and alcohol use are higher in older than younger people.

The report also says that substance use disorders in older people are frequently accompanied by complex psychiatric problems, and many older people show complex patterns and combinations of substance misuse, such as problem alcohol use and inappropriate use of prescription drugs.

What sort of substances do older people abuse?

The report covers legal medication, tobacco, alcohol and illegal drugs, as well as illicit “street” use of prescription and over-the-counter drugs.

Regarding use of prescription and over-the-counter medication, the report says that rates of misuse are high, particularly in older women. Although alcohol use declines with age, a significant number of older people consume alcohol at dangerous levels. While illicit drug use is currently uncommon in over-65s, the report projected that this would increase as people who are over 40, who use illicit drugs in significantly increasing numbers, get older.

It also says there is growing evidence that older people may be using a combination of legal and illegal drugs, as well as prescribed and over-the-counter medications. This practice, known as polypharmacy or polydrug dependence, is a particular problem in older people with physical and mental health problems. For example, patients may be offered, borrow or share out-of-date medications, take foods or drugs that interact or forget what drugs they have taken.

The report also says that older men are at greater risk of developing alcohol and illicit substance misuse than women, but older women have a higher risk of developing problems related to the misuse of prescribed and over-the-counter medications.

What are the risk factors for developing substance misuse in older people?

The report says that physical health problems and the long-term prescription of medications, such as hypnotics, anti-anxiety drugs and painkillers, are important factors in the development of substance misuse.

Psychosocial factors such as bereavement, retirement, boredom, loneliness, homelessness and depression are all associated with higher rates of alcohol use. It is possible that poorer cognitive function and mental health problems, such as anxiety and depression, contribute to substance misuse. However, the relationship is complex and it is unclear whether mental health problems lead to substance abuse or the other way around.

How big is the problem of substance abuse among older people?

The report does not give a figure for the overall proportion of older people with substance misuse problems. However, it says that estimates from Europe suggest the number of people over 65 with a problem will more than double between 2001 and 2020.

Below are some more figures from the report:

  • Between 1992 and 2008, the highest alcohol-related death rates were in men and women aged 55-74.
  • In 2008, over one-fifth of older men reported drinking more than four units of alcohol on at least one day of the week, while 10% of older women reported drinking more than the recommended maximum of three units.
  • During 2008-2009, 4.8% of over-45s in the UK reported use of an illicit drug in the previous year. The most significant problem for the over-40s was heroin use, either alone or in combination with crack cocaine.
  • Although smoking rates are lowest in people over 60, 13% of men and 12% of women in this age group smoke. 

Why does the college say that older people should drink less?

The report says that because of physiological changes associated with ageing, older people are at increased risk of experiencing adverse physical effects from substance misuse, which includes drinking relatively modest amounts of alcohol. Alcohol, together with tobacco use, has the greatest impact on physical health for older adults, causing cardiovascular, gastrointestinal, neurological and respiratory problems.

The report also points out that older people tend to have higher blood levels of alcohol than younger people who drink the same amount. The difference can be attributed to a lower body-mass-to-water ratio and a less efficient metabolism. There is also ample evidence that the threshold at which alcohol causes harm is lower in older drinkers than in younger people.

In older people, heavy prolonged alcohol misuse may increase the risk of developing vascular dementia or Alzheimer’s disease, may have other indirect effects on brain cells, and may have a direct toxic effect, producing “alcoholic dementia”.

As people age, their ratio of body water to fat falls and their liver becomes less efficient, which can increase the effects of alcohol and other substances. The responsiveness of the brain also alters, so that alcohol produces a more rapid depressant effect, resulting in impaired co-ordination and memory, for example.

What are the current recommended drinking limits?

The current recommended drinking limits are a maximum of four units a day for men and three units for women. One unit of alcohol is 8g or 10ml of pure alcohol. This is the equivalent of a third of a pint of 5%-strength beer, half a standard (175ml) glass of 12% red wine, or a 25ml single measure of 40% spirits.

What does the college want to happen now?

The report says that the currently recommended safe limits for alcohol are based on younger adults and are too high for older people. Recent evidence suggests that the safe upper limit for older people is 1.5 units a day, or 11 units a week.

The authors also say that binge drinking in older people should be defined as more than 4.5 units in a single session for men and more than 3 units for women.

Overall, the report says that older adults need to be given more attention as they are currently “invisible” in terms of service provision, clinical guidelines, research, healthcare policy and the training of health professionals. For example, it says GPs should screen all people over 65 for substance misuse as part of a routine health check, while more research is needed into treatment and management of substance misuse in this age group. It also points out that treatment of both coexisting physical and psychological conditions is an important part of management. Training health professionals about the impact of substance misuse in older people “is not an optional extra”, it argues.

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