Older people

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The world’s population is ageing rapidly, with the proportion of adults aged over 60 years expected to double from around 605 million to 2 billion people between 2000 and 2050 [1156]. 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 comorbid mental health disorders among older people, and how these differ from younger populations [277].

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, and one-in-four deaths from self-harm are among this age group [1156]. However, mental illness is often difficult to identify due to comorbidity with 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, social isolation, financial difficulties, diminishing cognitive function, and reduced capacity to self-care and manage their affairs [277]. Depression and suicide are also easily overlooked among older adults, and people who are socially isolated without supportive networks are at particular risk [277].

Similarly, AOD and mental health conditions are often overlooked or misdiagnosed among older adults, who are uniquely at risk of AOD-related harms. The ageing process can enhance the brain’s sensitivity to adverse effects of AOD use [1157], and older adults are significantly more likely to be prescribed medication with abuse potential, with one-in-four adults prescribed psychoactive medication [1158]. This is 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 [277]. Other factors that may contribute to the increased risk of AOD use problems in older adults include [1159]:

  • 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.
  • 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.
  • More medications available for a range of conditions, which may be a contributing factor in the increased use of psychoactive substances.
  • Opioids 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 help for comorbid mental health and AOD use disorders [1160]. Several barriers that may prevent older adults from accessing treatment include [1161]:

  • Transport, mobility, language, visual, or hearing difficulties, particularly for those who are frail or housebound, in rural or remote areas.
  • Social isolation.
  • 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 aging 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.
  • Social isolation which can result in serious problems going undetected.

It is critical to be aware that older adults with comorbid 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 interventions. The following may be useful for AOD workers managing and treating older adults [1161]:

  • Ensure AOD programs are age-specific, supportive, non-confrontational, aim to build self-esteem and foster an environment of respect.
  • Ensure risk assessments are conducted (see Chapter B3), 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 B4), and take care to foster links with medical, aging, 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.