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A QUESTION OF VALUES Substance misuse THE ELDERLY

A QUESTION OF VALUES Substance misuse THE ELDERLY

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A QUESTION OF VALUES Substance misuse THE ELDERLY

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  1. Professor Ilana Crome Keele University 21 March 2013 A QUESTION OF VALUES Substance misuse THE ELDERLY

  2. Thanks to colleagues and friends • Prof Peter Crome • Dr Tony Rao • Dr Martin Frisher • Dr Roger Bloor • Dr Alex Baldacchino • Drs Ishbel Moy & Harvinder Sidhu, our future! • And many other collaborators…

  3. Professor Ilana Crome Dr Karim Dar Dr Stefan Janikiewicz Dr Tony Rao Dr Andrew Tarbuck

  4. OVERVIEW • Why is it important • What current research tells us • How do we deal with it now • The future • Peter’s contributions

  5. Peter’s Principles • Style - Non judgemental, non confrontational • Demystify and destigmatise • What’s special and distinctive? • Proactive and positive • Evidence and uncertainties • Chronic disease - resilience but vulnerability • Dignity, integrity, (e)quality and compassion

  6. Substance misuse is:

  7. WHY IS IT IMPORTANT? Harms cost

  8. WHY IS IT IMPORTANT? • Scale of the problem • Burden of disease • Lifespan issue • Mortality • Financial costs • Societal impact

  9. CONTEXT • Older people will constitute ~25% of the UK population by 2020; currently 18% over 65s • Overall increase in older people using alcohol and illicit substances over past decade • National surveys of alcohol, illicit drugs, prescription drugs, presentations to Accident and emergency units, presentations to specialist services, hospital admissions (poisoning, drug related mental disorders, alcohol related physical disorders) • Prediction: set to double in the next 2 decades

  10. How much do older people use? • 13% men,12% women over 60 still smoke • Smoking largest cause of premature death • 45% NHS prescriptions for over 65s, twice • Alcohol consumption above adult ‘safe limits’: 20% in men, 10% in women over 65 • Highest alcohol death rate in aged 55-74 • 5% over 45s used any illicit drug over the previous year, 0.7% used a Class A drug • Increasing over 40s coming into treatment – 17% in drug treatment units are over 40

  11. EUROPEAN DISEASE BURDEN ATTRIBUTABLE TO SELECTED LEADING RISK FACTORS (2000) Number of Disability-Adjusted Life Years (000s)

  12. Most difficult to give up(among those who consume in previous year) NIGHT LIFE AND RECREATIVE DRUG USE IN EUROPE A study in 10 European Cities 1998

  13. Lifespan perspective Early life difficulties – maltreatment, distress – associated with substance use disorder and psychiatric comorbidity 90% people who use substances problematically have started before the age of 19 Addiction can be a life long problem

  14. Cannabis case grandmother is spared prison

  15. Peter’s contribution NO LONGER ONLY A YOUNG MAN’S DISEASE ILLICIT DRUGS May 2011

  16. POISONING - ANTIDEPRESSANTS May 2011

  17. POISONING - PARACETAMOL May 2011

  18. PERSPICACITY May 2011

  19. Per capita alcohol consumption in the UK, 1984-2008

  20. Alcohol-related mortality per 100,000 in the UK from 1984 – 2008 trebled

  21. DRUGS Increased for a decade £15 billion per annum 300,000 children 3% - £ 0.5 bn – NHS 6% - £1bn - deaths 90% is due to crime Harms and costs • ALCOHOL - all time high • 3rd leading cause of death • £21 billion per annum • 1 million children • £2.7 billion - health • ~£7 billion crime-related • £6.4 bn - workplace • Family, friends and wider communities - not quantified – child protection, divorce, homeless

  22. COSTS – GREATER FOR OLDER • More than 10 times -The cost of alcohol-related inpatient admissions in England for 55 to 74 year olds was £825.6m compared to £63.8m for 16 to 24 year olds in 2010/11. • 8 times as many 55 to 74 year olds (454,317) were admitted as inpatients compared to 16 to 24 year olds (54,682). • The cost of alcohol-related inpatient admission was £1,993.57m, over 3 times greater than the cost of A&E admissions, £636.30m. • The cost of alcohol-related inpatient admissions for men was £1,278.4m, just under double the cost for women, £715.1m.

  23. PRICING AND POLICY

  24. HARMS Distinctive RISKS AND COMPLICATIONS

  25. Distinctive issues • Substance use decreases with age, but can be more dangerous • Older people are at increased risk of the adverse physical effects as substances accumulate due to decreased metabolism • Brain sensitivity to drugs may be increased • Women metabolise faster; more severe effects earlier, present later; more comorbidity • May not have dependence eg withdrawal

  26. Distinctive issues • INTERACTIONS AND MISTAKES • Physical and mental health problems – eg sleep, anxiety, pain - hypnotics, anxiolytics and analgesics with abuse potential • Complexity, long term chronic disorders • Self management in partnership – embedded in preventative, communities and team based, continuity, responsive, flexible coordinated and integrated

  27. Precipitants and complications • Self harm a serious risk • Psychiatric problems associated with substance use eg intoxication, withdrawal, dependence, anxiety, depression, psychosis, cognitive dysfunction • Psychosocial factors eg bereavement (spouse, friends, family), retirement, boredom, loneliness, homelessness, loss of income,

  28. Alcohol with symptoms • PETER HAS SEEN ALCOHOL PROBLEMS IN MEMORY CLINIC • Memory problems 22.5% • Sleeping problems 38.5% • Feeling sad or blue 16.8% • Tripping, falling 17.8% • Gastrointestinal 24.1%

  29. Physicians should notice alcohol use complications • Hypertension 30% • Depression 12% • Gout 7.6% • Diabetes 5.2% • Ulcer disease 4.1% • Liver condition 3.5% • Pancreatitis 0.6%

  30. Alcohol with medications • Antihypertensives 31.7% • Ulcer medications 18.2% • NSAID 17.9% • Antiplatelet 17.3% • Non-prescription 12.7% • Antidepressants 11.9% • Sedatives 10.1% • Opioids 6.7% • Nitrates 4.3% • Warfarin 4.4% • Seizure 0.6%

  31. How do we deal with it now?

  32. BARRIERS TO DETECTION – AND HOW TO RESPOND • Training – competence, screening tools • Stigma, moral weakness – non-judgmental, non-confrontational • Under-reporting – comprehensive history • Mis-attribution of symptoms, under-diagnosis – awareness of subtle presentations, high index of suspicion • Ageism – ‘that is all she has left’ • Stereotyping – older, higher social class, more educated, women

  33. DETECTION - AWARENESS • Altered/erratic behaviour or symptoms • Poor response to treatmentfor medical illness, request for prescription drugs, sharing, storing • Past personal history/family history of substance misuse & legacy of personal, legal, occupational deficits • Illegal activities

  34. THE 5 A’s • ASK – all drugs, dependence, ambivalence, non-judgemental • ASSESS – motivation, goals, complications • ADVISE – ‘brief intervention’ – feedback, information, self help material • ASSIST – coping strategies, hope, self esteem • ARRANGE – admission – severe addiction, polysubstance, social, comorbidity, relapse

  35. DAPA-PC Drug and Alcohol Problem Assessment for Primary Care (Blazer) • Computerized screening systemquickly identifies substance problems in primary care • Can be used by psychiatrists as well • DAPA-PC is self administered, internet based, automatic scoring • Generates patient profile for medical reference • Presents unique motivational messages and advice for the patient

  36. Information technology • Save clinicians’ time • Patients to be screened in the waiting room • Clinician to follow-up with a patient only when prompted by the results of screen • Computerized screening may lend itself to a more honest revelation regarding drug use compared with face-to-face discussions. • Acceptability of computers by the elderly will only increase.’ • Peter has been interested in this for a long time

  37. CURRENT RESEARCH WHAT DOES IT TELL US? Treatment and Policy

  38. Alcohol dependence was last among 30 medical conditions in proportion of care received as evidence would recommend Source: McGlynn E., et al., (2003). The quality of health care delivered to adults in In the United States. New England Journal of Medicine, 348.

  39. Trials and guidelines • Usually dictated by clinical trials • Complex patients excluded ie unrepresentative samples eg older, substance users, comorbidity • Combined treatments rarely studied • Guidelines are not for older people

  40. May 2011

  41. Pharmacological treatments

  42. May 2011

  43. Peter’s first randomised clinical trial! May 2011

  44. Pharmacological treatment