The world’s population is ageing rapidly. In Australia, it is estimated that the proportion of adults aged over 65 years will increase from approximately 15% in 2017 to 21-23% in 2066, whilst the proportion of adults aged over 85 is expected to double over the same period from around 2% to 4% [1886]. Increased life expectancy, better health care, and decreased infant mortality across Australia are contributing to the increasing proportion of older people in the Australian community, and there is a need for AOD workers to be aware of the presentation and management of co-occurring mental disorders among older people, and how these differ from younger populations [431].
Rates of AOD use among older Australians are increasing, with the highest rates of daily drinking found among people over 70 [1780]. The proportion of older Australians presenting for some AOD treatment services, such as withdrawal management and pharmacotherapy, have also increased from 2018-19 to 2019-20 [1887, 1888]. In 2019, Australians aged over 60 also accounted for one third of all drug-induced suicides, both intentional and unintentional [1652].
Internationally, more than 20% of adults aged over 60 years have a mental health or neurological condition, the most common of which are dementia and depression [1889]. One-in-four deaths from self-harm are also found among this age group [1889]; however, suicide rates overall are not elevated among older (65+) Australians compared to middle-aged (35-64) Australians [1890]. Co-occurring conditions are common, with one medical chart audit of an older adult-specific AOD treatment service within Australia reporting that 89% of clients had at least one co-occurring mental health condition, the most common of which were depression (67%) and anxiety (53%) [81]. However, mental illness is often difficult to identify due to co-occurring physical health problems, injuries, and disabilities. Older people may have many contributing risk factors for mental illness, including bereavement, loss of social roles due to ill health or retirement, loss of autonomy or independence, social isolation, financial difficulties, diminishing cognitive function, and reduced capacity to self-care and manage their affairs [431, 1891, 1892]. Depression and suicide are also easily overlooked among older adults, and people who are socially isolated without supportive networks are at particular risk [431, 1893, 1894]. National Australian data suggests that suicide rates are also elevated among people with chronic pain, which is more common among Australians aged over 60 [1895]. Similarly, AOD and mental health conditions are often overlooked or misdiagnosed among older adults, who are uniquely at risk of AOD-related harms, as well as increased vulnerability to intoxication and overdose [389]. The ageing process can enhance physiological and cognitive sensitivity to adverse effects of AOD use [389, 1896].
International research has found that older adults are significantly more likely to be prescribed medication with abuse potential, with 25-53% of older adults prescribed psychoactive medication [1897, 1898], 23.9% of older adults receiving at least one potentially inappropriate prescription (the most common of which were sedatives and hypnotics) [1899], and 9.1% receiving excessive (>10) medications [1900]. Research from Australia has similarly found that one fifth to one half of older Australians are prescribed medications for durations that exceed recommended limits [1901], and 60% of older Australians receive potentially inappropriate prescriptions (the most common of which are opiates and benzodiazepines) [1902]. These factors are particularly problematic for people with dementia or cognitive impairment, and specialised medical practitioners in mental health services for older people need to maintain a proactive role in reviewing medications and advising appropriate prescribing practices for older people [431, 1903]. Other common co-occurring conditions and risk factors for AOD use among older adults who use AOD include anxiety, depression, sleep problems, delirium, chronic pain, and self-harm [1891, 1893, 1904–1906]. Other factors that may contribute to the increased risk of AOD use problems in older adults include [389, 1903, 1907–1910]:
- Reduced capacity to metabolise, distribute, and eliminate drugs; as such, the risk of AOD-related harm may increase if AOD use is not reduced as a person becomes older. These harms include an increased risk of falls and burns.
- An increase in disposable income, which may increase AOD consumption and associated problems.
- Life changes including new patterns of socialising, retirement, bereavement, and social isolation, which can be associated with changes in social roles and status.
- Reduced coping skills resulting from factors such as family conflict and bereavement.
- More medications available for a range of conditions, which may be a contributing factor in the increased use of psychoactive substances.
- Opioids, benzodiazepines, and hypnotic sedatives are increasingly used by older Australians, which can be harmful when used with other substances (e.g., alcohol).
- Increased use of opioid substitution programs, needle and syringe programs, and treatments for blood-borne viruses has prevented many premature AOD-related deaths, and, as a result, many long-term illicit drug users survive into older age and thus require ongoing treatment.
In general, older adults may be less likely to seek, or perceive the need for, help for mental health and AOD use disorders [1911, 1912]. Several barriers that may prevent older adults from accessing treatment include [1907, 1913]:
- Transport, mobility, language, visual, or hearing difficulties, particularly for those who are frail or housebound, in rural or remote areas.
- Social isolation, which can result in serious problems going undetected.
- Lack of time – older people may have other time commitments, including the need to care for others (e.g., spouse, friends, or grandchildren).
- The unappealing and unwelcoming nature of mixed-age clinical services, which older people may find chaotic.
- Ageism, negative stereotypes, attributing problems to the ageing process.
- A lack of awareness about mental health and AOD use problems among older people.
- Reluctance to ask older people sensitive questions that may be embarrassing.
- The perception that older people are too old to change their behaviour.
- The belief that it is wrong to ‘deprive’ older people from their final pleasures in life.
- Inability to identify symptoms of AOD and mental health conditions in older people.
- A lack of readiness to stop using AOD.
It is critical to be aware that older adults with co-occurring mental health and AOD disorders are not a homogenous group, and AOD workers and other health care providers will play a vital role in ensuring access to appropriate interventions. The following may be useful for AOD workers managing and treating older adults [389, 1906, 1907]:
- Ensure AOD programs are age-specific, supportive, non-confrontational, culturally sensitive, aim to build self-esteem and coping skills, and foster an environment of respect.
- Ensure risk assessments are conducted (see Chapter B4), and depression, loneliness, and loss are addressed. Assist the client to take steps to rebuild their social networks.
- Be flexible and conduct sessions at an appropriate pace.
- Where appropriate, involve families and carers.
- With the client’s consent, involve staff members who are interested and experienced in working with older adults.
- Practise care coordination (see Chapter B5), and take care to foster links with medical, ageing, and other relevant services. Be proactive with follow-up and care coordination.
- Take a holistic approach to treatment (see Chapter B1), and incorporate age-specific psychological, social, and health problems.