National Assembly for
Wales / Cynulliad Cenedlaethol Cymru
Health
and Social Care Committee/
Y Pwyllgor Iechyd a Gofal Cymdeithasol
Inquiry into alcohol and substance misuse / Ymchwiliad i gamddefnyddio alcohol a sylweddau
Evidence from Age Cymru – ASM 15 / Tystiolaeth gan Age Cymru – ASM 15
Consultation Response
Inquiry into alcohol and substance misuse in Wales
January 2015
1. Introduction:
1.1 Age Cymru welcomes this inquiry by the Health and Social Care Committee, and in particular the focus upon the experiences of older people. We are pleased that this issue is being taken seriously in Wales as demonstrated by the work of the Committee and the Welsh Government’s Substance Misuse Treatment Framework – Improving Access for Older People[1] published in October 2014.
2. General comments:
2.1 As a consequence of the recent publication of this Framework, it is not possible for us to comment at this stage upon its implementation or impact. However, it is clear from its content that the issue of substance and alcohol misuse among older people, and its treatment or lack thereof, has remained a ‘hidden’ problem for a population group whose needs are often overlooked
2.2 There is a clear gap in the existing research upon alcohol and substance misuse which largely focuses on younger adults. Yet, the recent publication on alcohol use in Wales by the Public Health Wales Observatory (PHWO) demonstrates that whilst levels of alcohol consumption are decreasing slightly among younger adults, they are persisting or indeed increasing amongst the 45+ age group[2]. According to the Welsh Government Substance Misuse Treatment Framework Consultation Document, there were 3783 people aged 50 or above who were referred for substance misuse treatment in Wales in 2012-2013[3] largely for alcohol misuse. This figure may belie the true scale of the issues given that alcohol and substance misuse often goes undiagnosed among older people, suggesting high levels of unmet need.
2.3 Further data needs to be collected to establish the extent of alcohol/substance misuse among older people in Wales, and referral rates for treatment or support.
2.4 Across the EU, there is a rise in alcohol-related mortality in older groups. Currently rates of alcohol-related disease are several times higher for men than for women[4]. As social norms with regard to alcohol consumption by women have changed, however, we may see rates amongst women increasing, in the same way that lung cancer rates continue to rise among women due to a later peak in female smoking rates.
2.5 Wales has an ageing population so demand for services/treatment for older people with alcohol or substance misuse problems is likely to increase. This trend is compounded by the fact that the consumption of alcohol has become more socially acceptable over recent decades[5].
2.6 Alcohol use places the health service under pressure, but also has broader implications for society and impacts upon the work of other agencies, such as social services and the police. Alcohol consumption can exacerbate chronic health conditions, and can have consequences for both physical and mental health. Hospital stays for alcohol-related admissions may be longer. There are risks associated with mixing alcohol with prescription medications.
2.7 The physiological changes associated with ageing influence our reaction to alcohol. The Royal College of Psychiatrists (RCP)[6] has argued that ‘safe levels’ of alcohol consumption are based upon research carried out with younger adults and may be too high for older people who have an increased risk of adverse physical effects.
2.8 Alcohol and substance use may be a sensitive subject for some older people who may see it as a private issue or who see a stigma attached to excessive use. For that reason, when developing approaches to treatment, it needs to be recognised that older people are not a homogenous group and that their reasons for drinking and how much they drink will be based on their personal circumstances, their biography and their socio-economic background[7].
2.9 Older people who misuse alcohol or substances will present to a wide range of agencies, not just healthcare. Often, due to the presence of other conditions or because symptoms are atypical, the underlying cause of misuse may be missed[8]. This highlights the importance of raising awareness among healthcare and other professionals. A range of services and agencies need to be able to identify and respond to problems effectively, requiring joint working and case management[9].
3 Early-onset and late-onset:
3.1 It has been estimated that around two-thirds of older people who drink excessively can be identified as early-onset drinkers[10], that is that they have been drinking heavily since their teens or twenties. They may be faced with certain chronic health problems that are associated with long-term alcohol misuse, for example liver cirrhosis, but they may also face problems associated with ageing that do not result from, but are aggravated by, their alcohol consumption. They may have a history of treatment for misuse, and longer-term support may be required for these individuals, especially if they feel they have ‘failed’ with previous treatment routes.
3.2 With regard to the other third of older people who drink excessively, these are generally identified as ‘late-onset’ drinkers, usually increasing their alcohol consumption during their 50s or 60s, often as a consequence of major changes in their lives or lifestyles. These can include bereavement, retirement and divorce[11]. According to the RCP, older men are more likely to be at great risk of becoming late-onset drinkers[12].
3.3 There is general agreement in the existing literature that late-onset drinkers have a better prognosis once diagnosed than early-onset drinkers, as they may have greater motivation to change their drinking habits, and tend to be drinking to excess rather than dependent on alcohol. However, they may not know where to go for help or what help is available[13], and this situation is compounded by the fact that the public health focus on alcohol has targeted the drinking behaviours of younger adults.
3.4 The triggers highlighted above can often lead older people to a greater feeling of loneliness or isolation. A number of the services that may have helped to tackle this root cause, such as day centres or Meals on Wheels, have been suffering from cut backs as a consequence of funding pressures, a situation further aggravated by the loss of public transport routes that are vital to older people, especially in rural areas.
3.5 There is a need to accord prevention among older people a higher priority. On the one hand, this requires recognition that there is a place for soft-outcome services, such as befriending and neighbourhood schemes, which can help to support late-onset drinkers who may be triggered by adverse life effects and loneliness. On the other hand, it also means that there is a need for awareness-raising of the impact of excessive alcohol consumption in prevention campaigns that are suitable for older people. Clearly there is value in campaigns that target excessive alcohol consumption among younger adults, but this is unhelpful if it leads to the issue being viewed as solely a young person’s problem. Older people who may wish to seek help or advice need to know how to access a service that is appropriate to their particular needs.
4 Substance misuse:
4.1 Substance misuse among older people can take different forms. Increasingly, as a consequence of the ageing of those generations that were more accepting of experimentation with substances during the 1960s and 1970s, there are older people for whom substance use has been on-going over a long period of time. They may already be in the system, but now face additional problems of older age that may or may not relate to their substance use.
4.2 There are also older people who start using illicit substances during later life, for a range of reasons, including adverse life events, pain management or because they have or had a partner who used illicit drugs[14]. For both of these groups, services need to be available that are age-appropriate and which understand the risk of co-morbidities with both the physical and mental health issues that may be present either as a consequence of substance misuse or deriving from the ageing process.
4.3 Another issue is the inappropriate use of prescribed and/or over-the-counter medicines. Unlike alcohol use, here it is women that are at greater risk than men of misusing the medicines or developing a dependence on them[15]. Medicine usage should be followed up during interactions with healthcare professionals to ensure that medicines are being used safely and appropriately.
5 Treatment:
5.1 Prevention and the shaping of age-appropriate prevention messages are crucial. Many who are drinking to access may not need specialist treatment, but could find appropriate support through other services highlighted below. In order to do so, however, they need to be aware that they are drinking to excess.
5.2 It should be recognised that many people do not find the use of units a useful measure with regards to alcohol consumption[16]. There are also concerns about whether the current safe levels are appropriate for older people, given that they are based on research into younger adults.
5.3 The Add To Your Life programme, a free online health check provided by NHS Wales for those aged 50 and over, refers to alcohol consumption in terms of units, which may lead to people under-estimating or confusing their levels of consumption. Given the targeted nature of Add To Your Life, this may offer a useful channel for disseminating age-appropriate messaging about alcohol consumption, but concerns have been raised that it lacks signposting to relevant further advice and help.
5.4 In addition to the questions raised about the appropriateness of the currently recommended safe levels for older people, concerns have been raised about whether the principal screening/diagnostic tools are appropriate for older people[17]. Once the Welsh Government’s Framework to improve access for older people has been implemented, a review should take place to ensure that appropriate screening/diagnostic tools are being used in assessment.
5.5 A number of barriers have been identified that may prevent the diagnosis of alcohol or substance misuse among older people[18]. These include ageism, under-reporting, misattribution, stereotyping and a general view that alcohol and substance misuse among older people is very rare, leading to the possibility of it being overlooked. Therefore healthcare and other professionals require training to ensure that symptoms are recognised. They need to be supported by having referral procedures in place. Effective referral can be undermined by the lack of a clear mechanism and by the time and other constraints existing within the health and care systems.
5.6 In particular, it has been suggested that professionals need to be open to considering the possibility of alcohol or substance misuse among older people who are frequently using primary care[19], A&E (fracture clinics) and mental health services, with some specific issues being identified as frequent unexplained falls, or patients doing much better in hospital but then deteriorating following discharge[20].
5.7 Whilst recognising the need for sensitivity, practitioners should not feel embarrassed to raise the issue with patients or, where appropriate, with family members, friends or carers, even where they are reluctant to discuss the issue. There is a need to understand the context in which the misuse is occurring and, indeed, a need to be aware that friends etc may be complicit or even, in extreme cases, that there is a safeguarding issue where alcohol is being used as a form of control[21].
5.8 The issue of alcohol or substance misuse is often dealt with in primary care. In order to ensure timely treatment, and the minimising of physical and mental health harms, early detection is crucial. The RCP has called for annual GP screening as a way of identifying excessive alcohol consumption[22].
5.9 However, even when a problem is identified/diagnosed, older people have been less likely to be given adequate treatment or, where appropriate, referred to specialist services[23].
5.10 Available specialist services are often targeted at, or sometimes even funded for working age adults – some services commissioned in the UK have an upper age limit for those they will treat[24]. Relevant services need to be open to/suitable for all ages with recognition that older people may benefit from one-to-one, rather than group support and that older people may feel uncomfortable in an environment oriented towards younger people or that tensions may develop between older and younger service users[25].
5.11 Many services that can benefit older people misusing alcohol or substances are facing funding pressures, or even discontinuation. This is not just true of specialist treatment services, but broader services such as transport – lack of transport facilities can be a barrier in accessing appropriate help[26] – or befriending which can help to tackle loneliness where this may have been a trigger for excessive alcohol consumption. In some instances, the third sector may be the appropriate source of a cost-effective service that is local, peer-led and operates in a way that doesn’t judge lifestyles. However, funding pressures in the sector means that useful services are being lost or only operate for a short period of time. Many older people who are drinking to excess may need support but not in the form of specialist services and the services that can help them are also being lost.
5.12 There is also concern in the existing body of literature about the suitability of the current detoxification model for older people, even where it is available. The Welsh Government consultation recognised that outpatient detoxification treatment may not be appropriate for older people who lack the necessary support to achieve the targeted outcomes[27]. Treatment/care plans need to take account of the availability of support networks, the age of onset and the presence of co-morbidities inter alia to ensure the older person gets the treatment or care most appropriate to their individual needs[28].
5.13 There are particular challenges associated with addressing the issue of alcohol or substance misuse among people with cognitive impairment which health and other relevant professionals need to be made aware of in order to ensure the most effective care and support possible[29].
6 Concluding remarks
6.1 Older people can, and do, benefit from treatment for alcohol and substance misuse. No-one should be denied access to effective treatment on the basis of age.
6.2 There is an evident need for awareness-raising, training and clear referral pathways for staff, supported by a clear local policy to which professionals can refer. This local policy should be derived from the WG framework to ensure its effective implementation, thereby enabling a subsequent review of its impact.
6.3 With regard to research, two issues need to be address: firstly, there is a clear need for further research into the effective treatment of these issues among older people; secondly, we need better data to establish the scope of the issue among older people in Wales so that services and treatments can be targeted effectively.