Elsevier

European Geriatric Medicine

Volume 2, Issue 4, September 2011, Pages 212-236
European Geriatric Medicine

Hot topic in geriatric medicine
Systematic and narrative review of treatment for older people with substance problems

https://doi.org/10.1016/j.eurger.2011.06.004Get rights and content

Abstract

Purpose

Substance misuse among older people is a growing concern. Treatment outcomes are perceived to be poor. The aim of the study was to examine the evidence for effective treatment for older substance misusers.

Methods

PubMed, The Cochrane Library, Medline, Project CORK, and EMBASE were searched up to January 2007. Trials were included if participants were over the age of 50, sample size was sufficient, follow-up was undertaken, baseline and outcome measures were reported, the design was randomised controlled (RCT), controlled without randomisation or non-experimental descriptive, and pharmacological or psychological treatments for alcohol, nicotine, prescription medications or illicit drugs were investigated. Sixteen papers met inclusion criteria.

Results

Most studies were carried out in the USA. Sample sizes ranged from 24 to 3622 (mean = 704) with follow-up from 1 month to 5 years (mean = 18 months). Eight randomised controlled trials and eight descriptive studies, covering alcohol with or without drug misuse (n = 11); methadone maintenance (n = 1), prescription drugs (n = 1), smoking (n = 3) were examined systematically. All had baseline and outcome measures, which varied across studies. Outcome depended on self-report in 11 out of 16 studies: most did not utilise biological measures or other corroboration. A range of psychological treatment interventions was tested. Older people do respond to treatment, do not achieve worse outcomes than younger counterparts, and sometimes do even better.

Conclusions

This is the first systematic review on this topic. These preliminary results show an optimistic picture, which provides a foundation for further research to determine the most appropriate treatments for this group.

Introduction

The proportion of the population over 65 years old will increase in the next 20 years. Projection studies have estimated that the number of adults over the age of 50 with substance use disorder will double, from 2.8 million in 2002–2006 to 5.7 million in 2020 [1]. In 1995, 49% of the “baby-boom” cohort, then aged 31–49, had used illicit drugs during their lifetime, compared to 11% of those over 50 [2]. In the United States, the lifetime prevalence rates for dependence on illegal substances are 17% for 18–29-year-olds, 4% for 30–59-year-olds and 1% for the over-60's [3]. This picture is mirrored in the British Crime Survey of England and Wales [4].

In the UK in 2006/2007, 18% of 55–59-year-olds and 23% of 45–54-year-olds reported lifetime use of drugs, 1.7% and 3.0% respectively reported use within the previous year, and 0.8% and 1.6% reported use in the previous month [5]. National statistics for treatment in the UK in 2007 showed that 4% of those who had received treatment in the previous 12 months were aged over 50 [6], though this proportion is increasing with time and is higher in London (14%). The number of drug misusers aged 40+ increased as a proportion of all adult drug misusers in treatment from 13% in 2004/2005 to just above 16% in 2006/2007, according to the National Drug Treatment Monitoring System [7]. Hospital Episode Statistics report increasing numbers of patients aged over 45 with primary or secondary drug-related disorders, including poisoning. As a result there will be an increased demand for specialist drug treatment services to cater for the needs of these elderly patients in the future.

Older people are particularly at risk from the harmful effects of substances, due to altered metabolism [8] and polypharmacy [3]. The presentation of such problems can be subtle and under-diagnosis and under-reporting may, therefore, have contributed to unreliable estimates of the level of problems associated with substance use [9]. An Australian study found low levels of detection and appropriate onward referral to specialist services of older problematic substance misusers by medical staff, some of whom believed that “to give up established habits is inappropriate” [10].

That these attitudes need to be challenged is characterised by the issue of smoking. Smoking tobacco is the largest cause of premature death in the UK, causing 106,000 deaths every year [11] and it has been shown that people who are well into middle age when they quit smoking can still avoid more than 90% of smoking-related lung cancer risk [12]. Forty-four percent of smokers aged 50 or over want to quit [13], but some older smokers think that they cannot stop or that they have already caused so much damage that quitting would not be beneficial to their health [14]. Strikingly, the number of deaths in the UK linked to alcohol has more than doubled, from 4144 in 1991 to 8386 in 2005, with the highest death rates found in men and in those aged 55–74 [15]. Illicit drug use also results in mortality – cohort studies have demonstrated between 12–22 times greater mortality rate in drug users compared with in the general population and older drug misusers are between two and six times more likely to die from a drug-related death [16], [17], [18]. The Office for National Statistics also reports increased deaths from drug misuse for over-40–69-year-olds from 1993–2005 [19].

To further complicate matters, older people obtain prescription drugs (e.g. codeine-based medications for pain or coughs and benzodiazepine tranquillisers or hypnotics for affective and anxiety disorders) from GPs or over-the-counter and, since they may not adhere to the instructions, they experience a wide range of adverse effects [20], including tolerance, withdrawal symptoms and compulsive use in the long-term [21].

While it is acknowledged that the prevalence of substance misuse in this age group varies according to the definitions of “elderly” (usually over 65 years in the UK, but often as low as 50) and “substance misuse” used [22], there are considerable grounds for concern that there are unmet needs within communities and that problems will increase. In the case of opiate misusers, over the age of 40 is regarded as “older” [7]. Definitions of substance misuse and dependence often used as the gold standard are derived from the DSM-IV [23] or the ICD-10 [24], but there is some debate as to whether these can be applied to older people.

There is a vast literature on the pharmacological and psychological treatments for adult substance misusers, from which evidence-based guidance and consensus statements have resulted [25]. There is no published guidance by the National Institute for Health and Clinical Excellence (NICE) on the treatment of older substance misusing patients or, in particular, older opiate dependent patients [26], [27], [28], [29]. The studies on which the recommendations are based exclude those over 65 (sometimes even over 50-year-olds), as well as those with physical and psychiatric comorbidities. The Department of Health recently produced revised management guidelines, which include a brief section on older addicts, where the older patient is defined as 40+ years [7]. The National Service Framework for the care of the elderly does not discuss addictions and substance misuse [30].

Given the rising numbers of older people with substance problems and the potential for effective treatment, exploration of the evidence base in the elderly population to date was undertaken to evaluate the interventions carried out. As far as we are aware, this is the first systematic review of studies on the treatment of alcohol, tobacco, illicit drug and prescription medication misuse in the older population.

Section snippets

Objectives

To determine whether there is evidence to support the treatment of substance misusing by older people and to discover which treatments, if any, are appropriate for this population.

Inclusion criteria

For the purposes of this study, older people were defined as those aged 50 years old or older. Trials were included if they looked specifically at older people, or if older people were part of a wider age range and the results for the older population were clearly described. Both pharmacological and psychological

Results

The information from each of the 16 studies was summarised and listed in order of date of publication and by the substance with which it was concerned. For the purposes of discussion, the two papers concerned with alcohol and drug abuse were included amongst the studies on alcohol and highlighted as such in the tables and Appendix A, as it was found that the majority of older patients in these studies only had an alcohol dependence problem. Eleven studies [32], [33], [34], [35], [36], [37], [38]

Discussion

Based on the limited evidence available, there is no indication that older people do worse than younger people in terms of outcomes after treatment for substance dependence and, in some cases, they may even do better. Whether this is related to a less serious degree of dependence, fewer associated problems, more supportive social networks, better treatment adherence, a longer time in treatment with older age, or to age itself, requires further investigation. It is possible that the patients who

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

Acknowledgements

We would like to thank Marion Riley and Corrina Knight for their secretarial assistance in this project.

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