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Article citation: Rahul (Tony) Rao, (2011) "Older people and dual diagnosis – out of sight, but not out of mind", Advances in Dual Diagnosis, Vol. 4 Iss: 1, pp. -
Substance misuse in older people is being increasingly recognised as a growing public health problem. A 50 per cent increase in the number of older people in the UK between 2001 and 2031 (Office of National Statistics, 2004) and a rise in the number drinking over weekly recommended limits by 60 per cent for men and 100 per cent for women between 1990 and 2006 (NHS Information Centre, 2009b) is now driving the need for a closer look at service provision for substance misuse in this age group. The number of people over 65 requiring treatment for substance misuse problem is also set to double between 2001 and 2020 (NHS Information Centre, 2009a). It is also striking that alcohol-related deaths remain highest in the 55-74-year-old age group (Office for National Statistics, 2009) and older drug misusers are between two and six times more likely to die from a drug-related death (Frischer et al., 1997).
Dual diagnosis in older people shows similar parallels. In primary care, there is an increased level of co-morbidity in the 75-84 age group compared with all age groups combined, largely attributable to benzodiazepine use (Frischer et al., 2003). In addition, a range of adverse psychological symptoms is associated with intoxication with and withdrawal from drugs and alcohol, including sedation, agitation, suicidal ideation, delirium and psychotic symptoms (Crome and Day, 2002). There are also special considerations in this age group, notably alcohol-related cognitive impairment. Although the relationship between alcohol and cognitive impairment is not straightforward, a distinction is made between primary alcoholic dementia and alcohol-related dementia. In the former, alcohol is the primary aetiological factor; in the latter, alcohol is a contributory factor (Oslin et al., 1998). It is clear that services are struggling to meet the needs of older people with dementia and cognitive impairment associated with alcohol misuse (Cox et al., 2004).
In spite of compelling evidence for a need to provide services for this vulnerable and often “invisible” group whose problems and suffering does not easily fall under the political spotlight, there has been no cohesive strategy to address this need. The National Service Framework for Older People (Department of Health, 2001) makes no mention of service planning for older people with dual diagnosis or even substance misuse alone. Likewise, policy documents from elderly care medicine mention substance misuse only in relation to delirium or falls (British Geriatrics Society, 2006, 2007). Some progress has been made in Alcohol Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence (NICE, 2010a). However, reference to the needs of older people is cursory, with some reference to the need for reducing the threshold for alcohol misuse when using screening instruments and assessing the severity of alcohol dependence and the need to consider in-patient care more readily for detoxification. It also notes the higher risk of alcohol-related harm in older people. One other valuable point raised is its acknowledgement that although drug treatments are not licensed for use in older people, there is no reason why should not be considered clinically effective in this age group. Similar public health guidance in Alcohol Use Disorders: Preventing the Development of Hazardous and Harmful Drinking (NICE, 2010b) highlights that mortality in this group is influenced by alcohol pricing, suggests the use of the AUDIT-5 as a suitable screening tool and emphasises the disparity between screening and brief intervention in older compared with younger people.
The most significant advance in highlighting the need for assessment and treatment of alcohol misuse has been the publication of the second report of the UK Enquiry into Mental Health and Wellbeing in Later Life (Age Concern, 2007). The report highlights several areas, notably the high rates of alcohol-related deaths in the 55-74 age group; the need to paying closer attention to “invisible” groups such as older people with alcohol and drug misuse problems; epidemiology and psychosocial risk factors (including dual diagnosis, ethnicity and social isolation); physical and mental health consequences such as falls/suicide and the detection, treatment and referral of older people with substance misuse, irrespective of age. UK policy on substance misuse and dual diagnosis in older people is overshadowed by similar policy strategies in the USA, which has produced a specific treatment intervention protocol guide for the implementation of substance misuse services for older people (US Department of Health and Human Services, 1998).
Dual diagnosis service provision for older people in the UK has historically been rooted in inadvertent age discrimination, which is no longer appropriate (Department of Health, 2009). Such policies should be based on the older people being able to access the most appropriate clinical service on the basis of need and not age per se (Royal College of Psychiatrists, 2009). The observation that as many as a third of older people with alcohol misuse problems develop them in later life (Council of Scientific Affairs, 1996) speaks for itself. Focussing on specific groups of older people who may be at particular risk of dual diagnosis (e.g. those with a previous history or those at risk due to stresses such as bereavement, retirement, social isolation, physical or mental health problems) may be helpful in preventing morbidity and mortality.
The management of alcohol misuse in patients with cognitive impairment or dementia presents a specific clinical challenge. These service users are unsuitable for specialist alcohol and drugs services as they lack insight and motivation in relation to their addiction, and are unable to engage with or retain information from individual or group interventions.
Care to this group falls to old age psychiatry services, but the degree of specialist input and advice from addiction services is piecemeal, often because much of the expertise lies in planning care pathways that involve older people’s social services, managing physical health and addressing behavioural problems. In this way, no one service can offer a seamless approach to care, but old age psychiatry and addiction services continue to work in silos. The harm reduction model for older people often involves a different type of “environmental manipulation”, for example, working with families to reduce the amount of alcohol they supply to the individual concerned. Similarly, a best interest model may mean using legal frameworks such as lasting powers of attorney or referral to the court of protection in patients who lack capacity or using best interest approach to seek placement in residential of nursing care. All this amounts to the need for services to work together.
Within specialist services there is a clear need for the development of clear local policies regarding older people with dual diagnosis. Policies should allow for easy transfer between services, joint-working and should delineate clear arrangements for which service will take the lead where two (or more) services are involved in the care of an individual patient. Policies should also cover arrangements for detoxification, including guidelines and administrative arrangements for organising in-patient detoxification admissions on an elective and emergency basis, both within the mental health unit and the general hospital. Sadly, such a vision has not borne fruit and large gaps remain in meeting the needs of older people with dual diagnosis.
In this themed issue, we keep the health and social care needs of older people with dual diagnosis very much in focus. In exploring the background literature and developing a dual diagnosis strategy (Rao and Shanks, 2011), we open up further avenues by examining how services can respond to the growing unmet need for older peoples’ dual diagnosis services (Rakshi et al., 2011; Andrews et al., 2011) and conclude with the development of the first dual UK training course designed for staff working with older people with dual diagnosis (Saxton et al., 2011).
To our knowledge, this is the first themed issue on dual diagnosis in older people in a peer reviewed journal. We hope that you find it both informative and as a catalyst for change within your own service. There will, no doubt, continue to be a demand for high quality research, service development and workforce planning in this ever growing are of practice.
Rahul (Tony) Rao
Consultant Old Age Psychiatrist, South London and Maudsley NHS Foundation Trust, London, UK
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Rakshi, M.G., Wilson, I., Burrow, S. and Holland, M.A. (2011), “How can older peoples mental health services in the UK respond to the escalating prevalence of alcohol misuse among older adults?”, Advances in Dual Diagnosis, Vol. 4 No. 1, pp. 17-27
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