Older people and substance abuse

WHENEVER ‘drug addicts’ or ‘substance abusers’ are mentioned, what usually spring to mind are images of young people high on drugs (or whatever illicit substances), wasting away their lives at some godforsaken place.

These images of bleakness are heart-wrenching. But there is another equally, but less obvious, sad scenario — substance abuse among the elderly, one of the fastest growing health problems in many countries. And Malaysia is not spared.

Generally, older people are considered mature enough to know what is right and wrong and as such, will not fall victim to substance abuse but that is beside the point.

In society, there are always people who fail to make a proper life for themselves or may have health problems not identified and treated, and thus, would end up destitute, unwanted and ignored. They are the most vulnerable groups who would resort to substance abuse to escape the harsh realities of life.

Substance abuse among senior citizens is sometimes referred to as a ‘hidden epidemic’.

According to consultant psychiatrist and addiction medicine specialist Professor Dr Philip George, who is also Malaysian Healthy Ageing Society (MHAS) president, the elderly casualties of such misery have been found to abuse all types of substance, the most common being alcohol, nicotine and some prescription drugs such as Benzodiazepine.

Benzodiazepines, sometimes called benzos, are a class psychoactive drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. They are used to treat insomnia, panic attacks, seizures, restless leg syndrome and alcohol withdrawal.

Dr Philip defines substance abuse as chronic or habitual use of any chemical substance to alter sates of body or mind other than for medically warranted purposes.

Even though the percentage of substance abuse among older people was still small, the situation could be considered serious and should not be ignored, he said after presenting a topic on Substance Abuse Among The Elderly at the Healthy Ageing Conference held in collaboration with the Sarawak Convention Bureau.

He revealed the heaviest substance abusers are people over 55 years old.

Alcohol abuse

Touching on alcohol abuse, he said it is a disorder, characterised by the excessive consumption of alcoholic products to the point of being addicted or dependent on it, thereby leading to physical and psychological harm.

“Addicts may also become a nuisance or a danger to others, or they may create family problems or jeopardise their own careers.”

According to him, the prevalence of heavy drinking — 12 to 21 drinks per week — in older adults is estimated at three to nine per cent.

As far as he has discovered or been made to understand, there are a number of reasons why elderly people turn to alcohol or drugs. Among the more common ones are being poor, living alone without any relatives or friends to socialise with, having encountered some form of losses recently or been ill for a while because of a progressive or chronic ailment.

There have also been some cases where a head injury has caused a change of mental attitude and behaviour in elderly people. To make matters worse, their excessive alcohol consumption would further jeopardise the functions of their brain.

Cases of seniors abusing alcohol or drugs tend to go undetected.

Dr Philip said those living alone would find it easier to hide their substance abuse while for those already mentally ill, turning to alcohol or drugs would damage their brain even more apart from affecting the well-being of the whole body.

He pointed out that older people were far more likely to suffer physical and mental damage as a result of alcohol or drug abuse, adding: “That’s because their body is less able to defend itself against such over-indulgence and this can mean their health will rapidly decline.”

Dr Philip further explained in older people, alcohol, for instance, could do a lot more damage to their health owing to reduced production of liver enzymes to deal with the intake of alcohol.

“Then there’s also a change in the fat-to-water body ratio which means there is less water in the body to dilute the amount of alcohol present.

“Also, tolerance levels for alcohol and drugs decrease with age. This means they can experience increasingly negative effects even when they are only using these substances at the same level as in the past.”

Substance abuse symptoms

According to Dr Philip, the symptoms of substance abuse among the elderly include manifesting some secretive behavior, very poor in remembering recent incidents, getting irritated easily when asked about their alcohol and drug use, loss of appetite, drastic mood changes when a bit high on the substance used, inability to concentrate, withdrawal from social life and exhibiting depression or irrational behaviour.

Symptoms which can be considered as already showing signs of alcohol abuse are a constant increase over time in the amount or frequency in the abusers’ alcohol consumption, their increased tolerance to the effects of alcohol, confusion, disorientation, blurred vision, gastrointestinal problems (nausea, vomiting), insomnia, unusual drowsiness, lack of physical coordination, malnutrition, slurred speech, urinary problems (incontinence, retention) and withdrawal symptoms like nausea, headache, anxiety, depression, sleeplessness even when less than the usual amount is consumed.

He said the National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends that alcohol consumption for adults, aged 65 and older, be limited to one standard drink (300ml of normal beer, 60ml of wine or 30ml of spirits) per day or seven standard drinks per week and no more than three drinks on one occasion.

As for benzodiazephines abuse symptoms, he said they included drowsiness, confusion, blurred vision, weakness, slurred speech, lack of coordination, difficulty in breathing, and coma.

At normal or regular doses, benzodiazepines relieve anxiety and insomnia.

He pointed out that despite their many helpful legitimate uses, benzodiazepines, when not consumed as prescribed, could lead to physical and psychological dependence on the drug, and if the abusers were made to stop taking the drug abruptly, they would display withdrawal symptoms like getting seizures or falling into a state of delirium.

 

Mental health problems

Dr Philip said certain underlying mental health problems could cause the elderly to resort to substance abuse, adding that they had a misconception they could use these substances to self-medicate.

He noted that about half of the individuals with severe mental health problems were also substance abusers.

“The causes include depression due to the many losses they have suffered upon getting old. For instance, they may have lost their energy and physical capability or their spouses or friends. Or they may be suffering from the side effects of the medication they are taking. Any one of these can drive them into depression and to use alcohol or drug to try and cope.”

He said it was important for them to know expert assessment of their condition and certain treatment could help them but unfortunately, many of these elderly people were also aware their image may be tarnished with a social stigma if they sought treatment, causing them to shun professional help.

 

Intervention

According to Dr Philip, diagnosis of substance abuse symptoms among the elderly may be more tricky because the symptoms sometimes mimic those of other medical and behavioural disorders common among older people, especially depression or dementia.

“Another factor which makes the phenomenon of substance abuse very elusive and not easily detected is that the abusers consider their habit as a private affair and refuse to seek professional intervention.

“It is, therefore, important that primary care doctors and nurses understand the need to get assessments done to identify those who may have been substance abusers, and work out some plan of intervention for them.

“If sufficient knowledge and research data are made available, healthcare providers can then work out bigger plans to ensure this elderly group of people can receive the needed treatment.”

He stressed that people should not just leave it to healthcare personnel to detect substance abuse among the elderly.

Friends, family members, caregivers or anyone else more intimately acquainted with the habits and daily routines of the persons concerned were very often the people in the best position to detect those behavioral changes that signalled a possible problem, he said.

Dr Philip listed some of the intervention efforts that could help elderly substance abuse victims:

l Age-specific group treatment that is supportive, not confrontative.

l Attend to depression, loneliness; address losses.

l Teach skills to rebuild social support network.

l Employ staff experienced in working with the elderly.

l Link with ageing, medical institutional settings.

l Content should be age-appropriate and offered at a slower pace.

l Create a ‘culture of respect’ for older patients.

l Broad, holistic approach recognising age-specific psychological, social and health aspects.

l Adapt treatment as needed to address gender issues.

 

Substance abuse in Australia

Another speaker, Dr Sadhana Maharaj, a consultant psychiatrist at the Canterbury Community Health Centre in Australia, said substance abuse among older people was also one of the fastest growing health problems in Australia.

She added that people with conditions of chronic pain such as from back injuries, previous traumas or vehicle accidents, tended to abuse the medication they were prescribed with, and since older people were more prone to developing delirium, they would often abuse sleeping tablets.

“Sleep has become a big problem, and often when they go to see a general practitioner (GP) for treatment, the easiest thing to give is sleeping tablets. We’re trying to move away from that now, and to give more natural ingredients of treatment like Melatonin. It’s not as cheap though – in fact, it’s cheaper giving Benzo than Melatonin.”

Melatonin is a natural hormone made by a body’s pineal gland. It is a pea-sized gland just above the middle of the brain. During the day, the pineal is inactive. When the sun goes down and darkness occurs, the pineal is “turned on” by the suprachiasmatic nucleus (SCN) and begins to actively produce melatonin which is released into the blood.

At this point, Dr Philip chipped in to say it was difficult to get natural medicines into Malaysia and even Melatonin is sometimes not available and only certain clinics have the product.

Resuming her dialogue, Dr Sadhana said self-medicating among the elderly was a concern, adding that there was a cohort of people, especially the war veterans, who suffered from post traumatic stress disorder (PTSD) which occurred after they experienced severe trauma or a life-threatening event.

“Even though there are lots of resources as well as psychological support to help them manage their PTSD, they tend to self- medicate. And there is a high rate of substance abuse incidence among them.”

She pointed out that this was largely because of easy access to medication products via the Internet.

“People can order Valium-like and Melatonin-like drugs from overseas and that too leads to dependency. In fact, substance abuse among young Australians is a growing problem. Amphetamines, ice, ecstasy are the common drugs they use.

“The immediate effects from Ice are intense pleasure and clarity. All drugs have the potential for dependency. One major issue we have been facing is they (drug users) seldom use single drugs but usually mix them with something else to enhance the effects which is very damaging to health.”

 

Medication abuse

Dr Philip said in Malaysia, access to medication via the Internet was also happening but more so among the younger generation.

“The age group largely affected are teenagers and young adults. This is the period of their lives when many have to cope with stress and when they get introduced to drugs and recommended to use them to cope with their stress, they would eventually become habitual users and dependent on the drugs.

“I think among the more effective prevention methods is empowering the youths rather than punishing them. Punishing usually would not stop people from using, but empowering may give them the will power to deal with life’s issues more realistically without resorting to drugs.”

He said in Sabah and Sarawak, amphetamine is a very common drug of substance abuse, while in peninsular Malaysia, the common ones are Heroin and Morphine.

According to him, the most common drug of abuse is cannabis but it is not so noticeable because users usually do not end up committing crimes and that’s why reliable official statistics on cannabis users are not available.

Dr Philip believed it is better to find effective ways to raise awareness among the people that substance abuse is really bad for them in the long run.