Assessing the mental health needs of older people
Derry A D (2000) Substance use in older adults: a review of current assessment, treatment and service provision Journal of Substance Use 5 pp.252-262.
The combined demographic increase in older people over 65 and changes in substance use patterns will present a challenge to agencies providing care and mental health interventions for this age group.
Research shows that the most common problem for this age group is alcohol abuse. Problems have been identified with the over-administration of medication and 'over the counter' drug use, particularly sedatives, hypnotics and tranquillisers. Use of illicit drugs has been hard to quantify, but is expected to rise as cohort attitudes change.
Social risk factors (such as bereavement), mental health problems (like depression) and physical health problems make the presentation of substance use problems in older people very complex. Substance use in older adults has different patterns to that of younger people.
Effective means of early identification and assessment of substance use problems, frameworks for understanding risk factors and intervention strategies need to be developed.
Identification of substance use in older people has been difficult, leading to the issue being hidden. Particular identification problems include the tendency of substance use to mimic the symptoms of other geriatric illnesses, a decreased propensity for older adults to self-report substance use and the tendency for carers and professionals to ignore, comply with or under-recognise substance use in older people.
Older people are less vulnerable to the negative social consequences of substance use and the routes through which problems are often identified, such as the workplace or the criminal justice system. Cognitive performance is frequently impaired by substance use, and this can often be indistinct from other health problems associated with old age.
It is thought that late-onset of substance use is often reactive to life-stressors and environmental factors.
Substance use in some older people, particularly those with mental health problems, may be an attempt to 'self-medicate'. Alcohol use and over-use of medication can be used to combat psychological problems and insomnia, but will also contribute to these. Older people reporting insomnia should also be assessed for drug/alcohol interactions.
Systematic, multi-disciplinary assessment should include accompanying health and functional impairment, social and familial circumstances as well as the substance use itself. The precipitating and maintaining factors need to be explored in the context of the care and/or family setting, especially where family or carers contribute to the substance use problem.
Assessments should rely on more than the self-report and methods need to accommodate the different behavioural, cognitive and biological indicators in older people. Although some specialist alcohol screening tools have been validated for use with older people, none assess the use of illicit and 'over the counter' drugs.
The clinical management needs to address the following issues:
- 1. social influences on substance use, including loss, isolation and housing problems;
- 2. activities of daily living;
- 3. nutritional and medical needs;
- 4. associated physical conditions;
- 5. associated cognitive impairment;
- 6. protection from exploitation;
- 7. mental health care.
The pace and content of intervention packages should be adapted to the needs of the older individual.
There is a need for some specialisation within broader older adult and substance use services. This could mean age-oriented treatment programmes, elder-specific substance use staff training programmes to improve identification, outreach and home detoxification programmes, preventative education and good interagency and interdisciplinary liaison.
In the absence of specialised services for older substance users, greater liaison between existing addiction services and services for older people can accommodate this service gap, exchange information and improve comprehensive assessment.