Elderly Are Society's 'Invisible Addicts,' Report Says

But Recommendation to Lower 'Safe' Drinking Limits Comes Under Fire

Deborah Brauser

July 01, 2011

July 1, 2011 — Not enough is being done to identify and fight substance abuse in the elderly, according to a new report by the Royal College of Psychiatrists (RCP) in the United Kingdom. Among other recommendations, the report calls for the lowering of "safe" alcohol limits in the elderly. However, some experts have raised concerns that this is not only unnecessary but could be downright "dangerous."

The report notes that elderly people often "show complex patterns and combinations of substance misuse," such as excessive alcohol consumption, as well as inappropriate use of prescribed and over-the-counter medications.

In addition, the researchers found a significant increase in illegal drug use in those older than 40 years and that almost a third of the older population with alcohol problems develop them later in life. Therefore, they recommend substance misuse screening by general practitioners (GPs) for all patients older than 65 years.

The traditional view is that alcohol misuse is uncommon in older people and that the misuse of drugs is very rare. However, this is simply not true.

"The traditional view is that alcohol misuse is uncommon in older people and that the misuse of drugs is very rare. However, this is simply not true," said chair of the RCP's Older People's Substance Misuse Working Group Ilana Crome, MD, professor of addiction psychiatry at Keele University Medical Center in Stoke-on-Trent, United Kingdom, in a release.

"A lack of awareness means that GPs and other healthcare professionals often overlook or discount the signs when someone has a problem. We hope this report highlights the scale of the problem and that the multiple medical and social needs of this group of people are not ignored any longer," she added.

The researchers also note that current government guidelines recommend "safe limits" on alcohol consumption based on standards for younger adults. However, because of physiological and metabolic changes that occur with aging, "these limits are too high for older people."

Instead, the report recommends that, based on past research, the upper safe limit should be 1.5 units per day or 11 units per week for older men and 1 unit per day or 7 units per week for women.

The report was released June 22.

Positive Effects of Alcohol Not Discussed

However, the International Scientific Forum on Alcohol Research notes that it is difficult to provide general guidelines for such a nonhomogeneous age group, which can include any type of physical condition, from marathon runners to the very sick and frail.

In a critique of the RCP report posted on its Web site, the International Scientific Forum on Alcohol Research writes that recommending a lowering of drinking levels for everyone older than 65 years to standardized "acceptable levels" is not appropriate and not based on reliable research.

The forum is made up of an international group of physicians and scientists, including epidemiologists, cardiologists, neurologists, statisticians, and public health officials.

The report was conspicuously lacking in a discussion of the important role that moderate drinking can play in reducing the risk of coronary heart disease, ischemic stroke, diabetes, dementia, and osteoporosis.

"The report was conspicuously lacking in a discussion of the important role that moderate drinking can play in reducing the risk of coronary heart disease, ischemic stroke, diabetes, dementia, and osteoporosis," forum codirector R. Curtis Ellison, PhD, professor of medicine and public health at Boston University School of Medicine in Massachusetts, told Medscape Medical News.

Dr. R. Curtis Ellison

"Advising healthy people over the age of 65 who are moderate drinkers to stop or markedly reduce their drinking would not be in their best health interests. In fact, that's the last thing we'd want them to do because it could actually be dangerous to their health," he added.

The critique notes that the report does not discuss the possible health benefits of polyphenols in the diet, which may act to protect the brain and have been shown to reduce the risk for certain diseases.

"Moreover, wine polyphenols protect against Alzheimer's disease. While wine and other beverages that contain alcohol can obviously be abused, moderate drinking has been shown in many studies to be an important component of a healthy lifestyle."

Although current US guidelines consider more than 1 drink per day "at-risk drinking" in this population, "there is little science to support this restriction."

"Forum members consider it very important to identify abusive drinking among the elderly, and this report provides specific and very reasonable recommendations to assist practitioners," they write.

However, "scientific data are consistent in demonstrating that quality of life is better and even total mortality is lower among moderate drinkers than among nondrinkers."

Increasing Heroin Use

"Both alcohol and illicit drugs are among the top 10 risk factors for mortality and morbidity in Europe," according to the report authors.

They add that the weekly recommended drinking limits in the United Kingdom have increased by 60% in men and by 100% in women between 1990 and 2006.

"While younger excessive drinkers often make the headlines, we should remember that older people often turn to alcohol in later life as a coping mechanism. And this can remain stubbornly hidden from view," said Don Shenker, chief executive of Alcohol Concern, in a statement.

"This report calls for much greater recognition that excessive drinking in older age is both widespread and preventable, particularly if public health professionals are supported and trained to spot the signs and take appropriate action."

The RCP report also notes that a recent study found that 4.8% of those older than 45 years reported using an illicit drug in the previous year and 0.7% reported using a Class A drug.

"Although the number of people coming into treatment has fallen across all other age groups, it has been rising for people aged 40 and over since 2005 to 2006," they write.

"The main problem for this age group is heroin, either alone or in combination with crack cocaine. A quarter started using in the past 5 years, and 27% appear to have been using drugs for 25 years or more."

The report calls for public health campaigns that specifically target the elderly and increased training in elder substance use disorders for all physicians, nurses, social care workers, and allied health professionals.

This timely report is a wake-up call for healthcare professionals and a reminder that older people have particular risks. Our challenge is to improve the detection of these individual addicts and offer the treatments which we know can transform people's lives.

"There is accumulating evidence that the treatment for alcohol and drug misuse in older people is effective and that [they] often stay in treatment for longer than younger people," write the researchers.

Chair of the RCP's Faculty of Addictions Psychiatry, Owen Bowden-Jones, MD, noted in a statement that "there is a generation of older people for whom these problems have gone undetected" due to the misconception that misuse is only a concern of the young.

"This timely report is a wake-up call for healthcare professionals and a reminder that older people have particular risks. Our challenge is to improve the detection of these individual addicts and offer the treatments which we know can transform people's lives," he said.

Dr. Ellison reports that the Institute on Lifestyle and Health at Boston University, where he is a director, has received financial support in the past from companies in the beverage industry but that these companies were not involved in any of the reviews conducted there.

Royal College of Psychiatrists. Report 165: Our Invisible Addicts. Released June 22, 2011.

International Scientific Forum on Alcohol Research. Critique 045: Alcohol Drinking in the Elderly: Risks and Benefits. Released June 26, 2011.

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