Dr Tony Rao Consultant Community Old Age Psychiatrist

South London and Maudsley NHS Foundation Trust and Institute of Psychiatry Psychology and Neurology

“It would be too optimistic to suppose that the relative under-representation of subjects in the older age groups among clients of information centres is just explained by older people having generally got the treatment they required or having reverted to normal drinking...it seems likely that this finding is in part a hint of the diminished life expectancy of the alcoholic” Professor Griffith Edwards

British Medical Journal 1967

1986

2011

The Baby Boomers

Turn 65

WHY NOW?

7.8

16

8.6

17

10.2

19

12

22

0

5

10

15

20

25

Population of England (million) % of Total

2001

2011

2021

2031

Projected population in England for people aged 65 and over

2001-2031

Over 65+ age group more likely to drink on 5 or more days of the week

Between 2000 and 2012, percentage of men and women in England

drinking over recommended limits increased by 50% and 100%

respectively

Number of people aged 65 and over admitted to hospitals in England for

alcohol specific disorders has increased by 40% over the past 6 years

In 60+ age group and over, hospital admissions in England for mental and

behavioural disorders associated with alcohol use outnumber those with

alcohol related liver disease.

Number of people aged 60 and over admitted to hospitals in England

with alcohol related brain injury has risen by over 140% over the past

10 years, with an almost static rise in the 15-59 age group

Population of aged 65+ age group and above in England and Wales

increased by only 11% between 2001 and 2011

Older Drinkers- A Growing Public Health Burden

Trends in drinking patterns in older people

General Lifestyle Survey (ONS, 2013)

Between 2005 and 2013, percentage of men drinking 8 or

more units of alcohol on any 1 day in past week reduced by

5% in 65+ age group

12% in 45-64 age group

19% in the 25-44 age group

30% in the 19-24 age group

Older people more likely to: Drink every day

Drink alone

Drink wine and spirits

Compared with working age population

WHY HERE?

• 43% showed alcohol dependence

• 71% suffered physical problems

• 57% admitted to mental health unit or went to A&E

• 21% showed ‘harmful use of alcohol’

Older people drinking above recommended limits

referred to N Southwark Community Mental Health Team

1991-1997 1998-2004 Men aged 75+ 21.7/100,000 25.7/100,000

Alcohol-related mortality in men - London

(Office of National Statistics)

2008-2010 Men aged 75+ 64.9/100,000

Alcohol-related mortality in men - Southwark (Office of National Statistics)

Policy into Practice

Recommendations from Our Invisible Addicts Policy level Developing clinical guidelines through care pathways

Public health level Developing consensus on drinking limits

Educational level Developing training packages for health professionals

Service delivery level- Removing barriers to assessment and treatment

Treatment intervention level- Exploring drug treatment interventions

Research and development level- Improving knowledge base for effective

treatments from epidemiological research and exploring barriers to service

provision from clinical audit

Ethical level- Developing, implementing and promoting service delivery

based on need, in age-appropriate way via multi-agency partnership

Other recommendations and strategic direction

When Jeanne Calment of Arles reached her 117th birthday in 1992, a local paper reported that she was being pressed by those in her nursing home to give up cigarettes — though she smoked only one or two a day — and port, which she loved. I was reminded of that hateful story last week, when the Royal College of Psychiatrists announced that people over 65 are drinking far more than is good for them, and that each day women should restrict themselves to a small glass of wine and men to less than a pint of average-strength pub beer

Dr Bully wants to snatch granny’s sip of sherry No doubt there are geriatric problem drinkers — but that does not justify this puritanical mass bullying

Editorial Group

Dr Tony Rao (Chair) Professor Ilana Crome (Addictions Faculty) Professor Peter Crome (British Geriatrics Society) Dr Anand Ramakrishnan (Old Age Faculty) Professor Steve Iliffe (Royal College of General Practitioners) Other members of Working Group Mike Ward (Alcohol Concern) Dr Amit Arora (Royal College of Physicians) Vivienne Evans (AdFam) Acknowledgements Martin Barnes (Drugscope) Ruthe Isden (Age UK) Dr Owen Bowden Jones/Professor Colin Drummond Dr Peter Connelly/Dr James Warner

Background • Developed over 3 years by experts working across health,

social care and voluntary sector

• Primarily for health and social care professionals, but can

inform commissioners, researchers, educators, policy

makers and voluntary/private sector

Terms of reference • Preventing people from dying prematurely

• Enhancing quality of life for people with long-term

conditions (including dual diagnosis)

Aims Recommend good practice for wide range of problems

Assist clinician decision making

Improve health and social outcomes

Substance Misuse in Older People: An Information Guide (2015)

General approaches to assessment, treatment and care Initial assessment of substance misuse in older people Psychosocial Interventions for substance misuse in older people Supporting families and carers Legal and ethical considerations Specialist Approaches to Substance Misuse The emergency physical presentation The emergency psychiatric presentation Managing withdrawal syndromes in the community Managing heroin/benzodiazepine substance misuse in the community Alcohol related brain injury Challenges to recovery Older women and alcohol misuse Drug interactions with substances Driving and substance misuse in older people

Alcohol and the Brain

Mechanism of alcohol neurotoxicity

• Direct toxicity- frontal and hippocampal damage

• Malnutrition-Wernicke’s encephalopathy/Korsakoff’s syndrome

• Metabolite toxicity

• Electrolyte imbalance

• Hepatic encephalopathy/Infection

• Inflammatatory (e.g. TNF α)

• Modifying factors (e.g. Apo allele/elevated homocsyteine)

Emergency Presentations

• Blackouts-predictive for both transient and

permanent brain damage

• Behavioural changes-judgment, attention,

psychomotor problems

• Falls-leading to traumatic brain injury

• Seizures

• Delirium Tremens

• Wernicke encephalopathy

Symptoms of Wernicke Encephalopathy

• ‘Classic triad’ of ocular motor abnormalities, cerebellar

dysfunction & altered mental state- only 20% of patients

present with the full triad

• Altered mental state occurs in 80%

– mental sluggishness, apathy, impaired awareness of

an immediate situation, disorientation, poor attention,

agitation, hallucinations

– Cerebellar dysfunction occur in 25% (loss of

equilibrium, gait disturbance, truncal ataxia,

dysdiadochokinesia and occasionally, limb ataxia or

dysarthria)

WERNICKE’S ENCEPHALOPATHY

Korsakoff’s Syndrome

Results from chronic alcoholism and consequent thiamine

deficiency

Severe anterograde amnesia

Severe retrograde amnesia extending years before damage

Confabulation - make up stories to fill in absent memories

Preserved short term memory

Often unaware of deficit

Alcohol related dementia - proposed criteria (Oslin 1998)

• Evidence of cognitive impairment

• Significant alcohol use as defined by the minimum average of 35

standard drinks per week for men and 28 for women, for a period

of greater than 5 years

• The period of significant alcohol use must occur within three

years of clinical onset of cognitive impairment

A probable diagnosis of ARD is supported by presence of:

1. Alcohol related hepatic, pancreatic, gastrointestinal,

cardiovascular or renal disease or other end organ damage.

2. Ataxia or peripheral polyneuropathy (not attributable to other

non-alcohol related causes).

3. Neuroimaging evidence of cerebellar atrophy (esp. vermis)

4. Cognitive damage and evidence of ventricular or sulcal

dilatation are likely to improve within the first 60 days, residual

damage will be slower to improve and may be permanent

The following cast doubt on a probable diagnosis of ARD

1. Significant language impairment (e.g. nominal dysphasia)

focal neurological signs or symptoms (except ataxia or

peripheral sensory polyneuropathy)

2. Neuroimaging evidence of cortical or subcortical infarction,

subdural haematoma or other focal brain pathology

3. Elevated Hachinski Ischemia scale score

Differentiating Alcohol Related Dementia from other dementias

Consistent findings of frontal lobe impairment from:

• MRI and fMRI imaging

• PET and SPECT imaging

• Neuropathology

• Neuropsychological testing (n.b. limitations of conventional bedside

tests such as SMMSE and AMTS)

• Frontal lobe function most affected in verbal fluency tasks

(Wilson, 2014)

ALCOHOL RELATED BRAIN DAMAGE

SOME UN-ANSWERED QUESTIONS

1. Rate of progression and possible ‘reversibility’

2. Interplay with other pathology and traumatic brain injury

3. Role of drug treatment in managing BPSD

4. A clear ‘dose-response’ relationship between alcohol

intake and irreversible cognitive impairment remains unclear,

but ‘safe limits’ in older people more likely to be adversely

affected by co-morbidity

Improving Care for alcohol related dementia

Poor access to services exacerbated by:

• Sensory deficits

• Poor mobility

• Social and cultural isolation

• Stigmatisation

• Depression and cognitive impairment

• Primary care services

• Social services

• Voluntary agencies

• Housing

• Old age psychiatry services

• Accident and emergency departments

• Care of the elderly day centres and hospitals.

Further compounded by different routes of access

Access to specialist alcohol services

Helping older people into treatment

• Accessing Services- Knowledge, Stigma, Denial, Ageism,

Family Collusion

• Specialist service provision- Tailoring services to cohort,

‘culture’, ethnicity, biological/physiological aging, personality

and social factors

• Time commitment - also a ‘richer vein of experience’

• Home based service delivery – ‘Empty bottles in the kitchen

bin’

Advantages of assessment using home based approach

CLEANLINESS

• Untidy/cluttered

• Squalid/infested

WARMTH

• Adequate heating

• Adequate ventilation

SAFETY, SECURITY & STRUCTURE of everyday routine

• Smoke alarm

• Falls hazards

• Safe storage of medication

• Security (includes bogus/’cold’ callers)

• Face to face contact

Multi-agency partnership

• Likely to be several agencies involved- substance misuse

services, old age psychiatry, geriatrics, primary care and social

services

• Some voluntary sector organisations may have experience with

older people but most do not

• Others such as wardens in sheltered accommodation, district

nurses, housing officers and community pharmacists also

invaluable

HOUSING

PRIMARY CARE

ACCIDENT AND

EMERGENCY

VOLUNTARY SECTOR

SOCIAL SERVICES

Falls

Alcohol withdrawal

Foundation 66

Alcoholics Anonymous Adfam

Age UK

Day Centre/

Home Care

Safeguarding

Alcohol screening Brief Intervention

General health screening

BME support

Health and Social Care

Care of the Elderly

Medicine

Specialist Housing & Continuing Care

Old Age Psychiatry

‘Wet’ Hostel Specialist

Dementia Care

Community detoxification Psychological

Interventions Substance

Misuse

Psychiatry

Specialist

residential rehabilitation

Comprehensive

medical review

Community

care coordination Physiotherapy

OT and Psychology

• Retrospective case note study

• Referrals to four older adult liaison psychiatry services 2006 to 2011

• 420 unique case notes identified; 108 patients eligible for inclusion

• 60 alcohol withdrawal syndrome (42 of whom had alcohol-related brain

injury)

• 14 were placed in continuing care facilities

• 50 taken on by community mental health teams (CMHTs): at 6 month

follow-up, 19 (38%) achieved abstinence from alcohol or controlled

drinking

• Patients with ARBI less likely than those without it to have changed

their drinking behaviour after

Integrated care in dual diagnosis (Rao, 2013)

First UK naturalistic study to show positive outcomes from community treatment of alcohol misuse and dual diagnosis

“Middle age is also the time when social drinking merges insensibly with the early manifestations of chronic alcoholism. It may be many months before the store of gin bottles is discovered in the kitchen cupboard In any event, in no case with a decline in memory for recent events, an unexplained attack of delirium or hallucinosis or a change in personality, should the possibility of alcoholism fail to be considered” Professor Sir Martin Roth

Journal of the College of General Practice 1964