Retirement, bereavement, change in home situation, infrequent contact with family and friends, and social isolation leading to an increase in alcohol consumption by older people

British Medical Journal, Substance misuse in older people, 22 August 2017:

Baby boomers are the population at highest risk

Developed countries have seen substantial increases in longevity over the past 20 years, contributing to a global demographic shift. The number of older people (aged over 50) experiencing problems from substance misuse is also growing rapidly, with the numbers receiving treatment expected to treble in the United States and double in Europe by 2020.1

In both the UK and Australia, risky drinking is declining, except among people aged 50 years and older.23 There is also a strong upward trend for episodic heavy drinking in this age group. This generational trend is not restricted to alcohol. In Australia, the largest percentage increase in drug misuse between 2013 and 2016 was among people aged 60 and over, with this age group mainly misusing prescription drugs. However, people over 50 also have higher rates than younger age groups for both past year and lifetime illicit drug misuse (notably cannabis).4

Of additional concern is the increasing proportion of women drinking in later life, particularly those whose alcohol consumption is triggered by life events such as retirement, bereavement, change in home situation, infrequent contact with family and friends, and social isolation. The rise of alcohol misuse in "baby boomers" (people born between 1946 and 1964) has also been noted in Asian countries.5

Older people with substance misuse show different characteristics but most fall into one of three groups: maintainers (unchanged lifetime patterns), survivors (long term problem users), and reactors (later uptake or increased patterns). The distinction is important because each requires different assessment, intervention, and treatment regimens.6

With alcohol being the most common substance of misuse among older people, underdetection of alcohol problems is of immediate concern. Alcohol misuse in the older population may increase further as baby boomers get older because of their more liberal views towards, and higher use of, alcohol. A lack of sound alcohol screening to detect risky drinking may result in a greater need for treatment, longer duration of treatment, heavier use of ambulance services, and higher rates of hospital admission.

Two systematic reviews of both descriptive and analytical trials found that treatment programmes adapted for older people with substance misuse were associated with better outcomes than programmes aimed at all age groups.78 Age adapted programmes resulted in less severe addiction, higher rates of abstinence, improved health status, and better aftercare. Assessment, treatment, and recovery plans require careful consideration of age specific clinical needs. Professionals need to consider the possibility of coexisting mental disorders such as cognitive impairment and depression (dual diagnosis), as well as complex physical presentations that may include the presence of pain, insomnia, or the non-medical use of prescription drugs. Older people with dual diagnosis use both inpatient and outpatient services more frequently than those with substance misuse alone.9 The management of substance use in older people can also be influenced by mental capacity, which may change with the onset of cognitive impairment.

Future healthcare for older people with substance misuse will continue to present challenges for service delivery, particularly with the growing influence of baby boomers. Some of the recommendations from the 2011 Royal College of Psychiatrists' report on substance misuse in older people (Our Invisible Addicts),10 such as examining safe drinking limits for older people, developing age specific skills in the assessment and treatment of substance misuse, and adapting services have been incorporated into an information guide for clinical practice.11 In the United States, the importance of better education for clinicians has already been noted.12 In the UK, a revision of Our Invisible Addicts is under way.

The baby boomer population also brings challenges to the diagnostic process, given the complexity of clinical presentations. Clinicians will need improved knowledge and skills in assessing and treating older people at risk of misuse of opiate prescription drugs, cannabis, and, increasingly, gabapentinoid drugs used to treat neuropathic pain and anxiety.13

Guidance for service commissioners has begun to acknowledge the needs of older people with substance misuse, particularly in the context of dual diagnosis.14 The Drink Wise Age Well project in the UK has also started to evaluate interventions for alcohol misuse in older people.15 But there remains an urgent need for better drug treatments for older people with substance misuse, more widespread training, and above all a stronger evidence base for both prevention and treatment.

The clinical complexity of older adults with substance misuse demands new solutions to a rapidly growing problem. So far, there has been little sign of a coordinated international approach to integrated care.

References

1.     ↵

Wu LT, Blazer DG. Substance use disorders and psychiatric comorbidity in mid and later life: a review. Int J Epidemiol2014;358:304-17. doi:10.1093/ije/dyt173 pmid:24163278.

2.     ↵

Office for National Statistics. Adult drinking habits in Great Britain: 2005 to 2016. 2017.https://www.ons.gov.uk/releases/adultdrinkinghabitsingreatbritain2015

3.     ↵

Australian Institute of Health and Welfare. National Drug Strategy Household Survey (NDSHS) 2016: key findings. 2017.http://www.aihw.gov.au/alcohol-and-other-drugs/data-sources/ndshs-2016/key-findings

4.    ↵

Kostadinov V, Roche A. Bongs and baby boomers: Trends in cannabis use among older Australians. Australas J Ageing2017;358:56-9.. doi:10.1111/ajag.12357 pmid:27730759.

5.     ↵

Nadkarni A, Murthy P, Crome IB, Rao R. Alcohol use and alcohol-use disorders among older adults in India: a literature review. Aging Ment Health2013;358:979-91.. doi:10.1080/13607863.2013.793653 pmid:23659339.

6.     <![endif]>↵

Nicholas R, Roche AM. Grey matters. Preventing and responding to alcohol and other drug problems among older Australians. Information Sheet 3. The silver tsunami: the impact of Australia's ageing population.National Centre for Education and Training on Addiction, Flinders University, 2014, http://nceta.flinders.edu.au/files/7014/1679/1083/EN559.pdf.

7.     <![endif]>↵

Moy I, Crome P, Crome I, Fisher M. Systematic and narrative review of treatment for older people with substance problems. Eur Geriatr Med2011;358:212-36. doi:10.1016/j.eurger.2011.06.004.

8.     <![endif]>↵

Bhatia U, Nadkarni A, Murthy P, et al. Recent advances in treatment for older people with substance use problems: An updated systematic and narrative review. Eur Geriatr Med2015;358:580-6. doi:10.1016/j.eurger.2015.07.001.

9.     ↵

Bartels SJ, Coakley EH, Zubritsky C, et al. PRISM-E Investigators. Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. Am J Psychiatry2004;358:1455-62. https://doi.org/10.1176/appi.ajp.161.8.1455.doi:10.1176/appi.ajp.161.8.1455 pmid:15285973.

10.   ↵

Royal College of Psychiatrists. Our invisible addicts: first report of the older persons' substance misuse working group of the Royal College of Psychiatrists. 2011. http://www.rcpsych.ac.uk/files/pdfversion/cr165.pdf

11.   ↵

Rao RT, Crome I, Crome P. Substance Misuse in Older People: an Information Guide. Cross Faculty Report FR/OA/A)/01.The Royal College of Psychiatrists, 2015,https://www.rcpsych.ac.uk/pdf/Substance%20misuse%20in%20Older%20People_an%20information%20guide.pdf

12.   ↵

De Jong CAJ, Goodair C, Crome I, et al. Substance misuse education for physicians: why older people are important. Yale J Biol Med2016;358:97-103. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4797843pmid:27505022.

13.   ↵

Evoy KE, Morrison MD, Saklad SR. Abuse and misuse of pregabalin and gabapentin. Drugs2017;358:403-26.doi:10.1007/s40265-017-0700-x pmid:28144823.

14.   ↵

Public Health England. Better care for people with co-occurring mental health, and alcohol and drug use conditions. 2017.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/625809/Co-occurring_mental_health_and_alcohol_drug_use_conditions.pdf

15.   ↵

Drink Wise Age Well. Impact report. 2016. http://www.drinkwiseagewell.org.uk/wp-content/uploads/2016/11/DWAW_AR16-LoResSpreads2.pdf

The question of marriage equality needs to be resolved

Over a two week period from 12 September 2017 an Australian Marriage Law Survey Form will be sent by post to every Australian registered to vote. It will be sent to the address given on the Commonwealth Electoral Roll.

This voluntary survey form needs to be returned before 6pm on 27 October 2017. If it is received by the Australian Bureau of Statistics after the deadline it will not be counted.

The survey form asks one straightforward question: “Should the law be changed to allow same-sex couples to marry?”

Trump the Demagogue

US President Donald J. Trump holds a rally at the Phoenix Convention Center in Phoenix, AZ, on 22 August 2017

Political meme of the Week

@MissBaileyWoof

Quotes of the Week

“TRUMP’S USE OF DECEPTION and untruthful affidavits, as well as the hiding or improper destruction of documents, dates back to at least 1973, when the Republican nominee, his father and their real estate company battled the federal government over civil charges that they refused to rent apartments to African-Americans. The Trump strategy was simple: deny, impede and delay, while destroying documents the court had ordered them to hand over.” [Kurt Eichenwald writing in Newsweek, 31 October 2016]

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“About the best way you can sum up Scott Morrison’s week is that he began it by accusing the ALP of raising taxes and he ended it by introducing a bill to raise taxes.”  [Greg Jericho writing in The Guardian, 20 August 2017]

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“The problem is that Kim Jon-un is largely the same personality type as Trump — both are paranoid, narcissistic and have huge egos…..We’ve never really had leaders like that on both sides before.” [Dr Genevieve Hohnen, Lecturer in Politics, Edith Cowan University, quoted at news.com.au, 15 August 2017]

Fate of politicians referred to the High Court over the citizenship saga will not be known until at least mid-October.

It appears that on Day One before the High Court of Australia there is to be no united defence by those sitting politicians defending their election as members of parliament and stories appear to be changing.

ABC News, 24 August 2017:

The fate of politicians referred to the High Court over the citizenship saga will not be known until at least mid-October.

The court held its first hearings on the cases in Brisbane today, and Chief Justice Susan Kiefel has ordered the matter be heard in Canberra on October 10-12.

It is not clear yet how long it could take the court to decide on the case and announce its decision on the five cases currently before it — those of Deputy Prime Minister Barnaby Joyce, former Nationals Minister Matt Canavan, One Nation's Malcolm Roberts and former Greens senators Larissa Waters and Scott Ludlam.

Solicitor-general Stephen Donaghue QC, acting for the Commonwealth, had urged the hearings be scheduled in mid-September to ease any concerns about the validity of decisions made by the 45th Parliament.

In another twist, Mr Joyce's political nemesis, Tony Windsor, has been given permission to join the citizenship challenge in the High Court.

Mr Windsor will argue Mr Joyce has breached the constitution, as he was a dual citizen of New Zealand.

Mr Windsor's lawyers, appearing by videolink from Melbourne, also argued for the right to cross-examine Mr Joyce if they needed it for their case.

Solicitor-general Stephen Donaghue QC, acting for the Commonwealth, urged the court to hear the matters by mid-September.

Chief Justice Kiefel said she understood the "unusual circumstances" of the challenges, and the "high level of urgency", given it would have an impact on the current make-up of the Parliament.

However, she raised concerns whether the matters could be dealt with that quickly, particularly when Deputy Nationals leader Fiona Nash and South Australian senator Nick Xenophon's cases were awaiting formal referral to the court.

Chief Justice Kiefel asked the solicitor-general whether there was a "real practical difficulty in terms of governance" if the court waited until October to hear the cases, to which Mr Donaghue replied there was not.

Lawyers for Senator Canavan also said the Commonwealth had "underestimated the complexity of their case", given the nature of his Italian citizenship.

They also suggested the highly publicised story he had presented about his mother signing him up for Italian citizenship was "irrelevant", rather arguing that there had been retrospective changes to Italian laws that had led to the strife.

Mr Donaghue said the cases of Senator Canavan, Mr Joyce and Ms Waters were different to those of Senator Roberts and Mr Ludlam.

He argued Senator Canavan, Mr Joyce and Ms Waters had no knowledge they could be considered dual citizens under foreign law.

The solicitor-general but suggested Senator Roberts and Mr Ludlam knew or should have known.

Lawyers for Senator Roberts criticised the initial timing of the full hearings, suggested by the Commonwealth.

They also took issue with the Attorney-General's offer to get the same British QC enlisted to give expert evidence on other citizenship cases to also draft a report about Senator Roberts' status.

The argument was that they should have the chance to brief the legal expert themselves, and have the opportunity to find their own experts if they did not agree. [my highlighting]

The Australian, 24 August 2017:

Barrister Robert Newlinds SC, for India-born Senator Roberts, said his client did not concede to being a citizen of any country other than Australia.

However, Mr Newlinds said Senator Roberts made contact with the British Home Office before the election, but received no response. He then sent another email before the election and “renounced” any foreign citizenship.

However, Senator Roberts did not receive any acknowledgement from the Home Office until after the election, the court has heard, when they sent him a renunciation form to fill out.

He later was told by the Home Office that his renunciation of British citizenship had been accepted – but Mr Newlinds said it was not clear whether that acceptance was in relation to the pre-election email or the post-election form……

Attorney-General George Brandis says the government is “grateful” the High Court agreed to hear all eligibility cases in the one hearing.

Senator Brandis said the hearing, to be held in the first fortnight of October, was scheduled as early as possible, despite the government asking for an earlier date on the 13th and 14th of September.

“We are very grateful that the High Court has listed the matter at the next practicable opportunity, we were pressing the court to hear it even earlier in September but it just wasn’t practicably possible particularly since the matter was going to be set down for three days,” Senator Brandis said.

“By the standard of listing matters in the High Court it is a very swift hearing, it gives all the parties a full opportunity to be ready, to present both written submissions and of course oral argument….. [my highlighting]

Matters for judgment by the High Court sitting as the Court of Disputed Returns:

NOTICE - Reference by the Senate to the Court of Disputed Returns - Senator Matthew Canavan

NOTICE - Reference by the Senate to the Court of Disputed Returns - Mr Scott Ludlam

NOTICE - Reference by the Senate to the Court of Disputed Returns - Ms Larissa Waters

NOTICE - Reference by the Senate to the Court of Disputed Returns - Senator Malcolm Roberts 

NOTICE - Reference by the House of Representatives to the Court of Disputed Returns - The Hon Barnaby Joyce MP

Lofgren introduces resolution urging Vice President and Cabinet to fulfil duties under 25th Amendment

It was only a matter of time......

“Amendment XXV

Section 4.

Whenever the Vice President and a majority of either the principal officers of the executive departments or of such other body as Congress may by law provide, transmit to the President pro tempore of the Senate and the Speaker of the House of Representatives their written declaration that the President is unable to discharge the powers and duties of his office, the Vice President shall immediately assume the powers and duties of the office as Acting President.

Thereafter, when the President transmits to the President pro tempore of the Senate and the Speaker of the House of Representatives his written declaration that no inability exists, he shall resume the powers and duties of his office unless the Vice President and a majority of either the principal officers of the executive department or of such other body as Congress may by law provide, transmit within four days to the President pro tempore of the Senate and the Speaker of the House of Representatives their written declaration that the President is unable to discharge the powers and duties of his office. Thereupon Congress shall decide the issue, assembling within forty-eight hours for that purpose if not in session. If the Congress, within twenty-one days after receipt of the latter written declaration, or, if Congress is not in session, within twenty-one days after Congress is required to assemble, determines by two-thirds vote of both Houses that the President is unable to discharge the powers and duties of his office, the Vice President shall continue to discharge the same as Acting President; otherwise, the President shall resume the powers and duties of his office.” [Cornel Law School, U.S. Constitution]

Democratic Party Representative Zoe Lofgren’s (D-Calif.), Press Release, 18 August 2017:

                                                                                                                                     

Lofgren introduces resolution urging Vice President and Cabinet to fulfill duties under 25th Amendment

Resolution cites President Trump’s “alarming pattern of speech causing concern that a mental disorder may have rendered him unfit”

Washington, August 18, 2017 

WASHINGTON, DC – Does the President suffer from early stage dementia? Has the stress of office aggravated a mental illness crippling impulse control? Has emotional disorder so impaired the President that he is unable to discharge his duties? Is the President mentally and emotionally stable?

Today, U.S. Representative Zoe Lofgren (D-Calif.) introduced a resolution that urges the Vice President and Cabinet to have the President examined by medical and psychiatric professionals to assist them in determining whether the President is unfit and unable to fulfill his Constitutional duties. Section 4 of the 25th Amendment of the United States Constitution outlines this obligation.

As the resolution reads, “President Donald J. Trump has exhibited an alarming pattern of behavior and speech causing concern that a mental disorder may have rendered him unfit and unable to fulfill his Constitutional duties.

“Many Americans, including many Republicans, have observed the President's increasingly disturbing pattern of actions and public statements that suggest he may be mentally unfit to execute the duties required of him,” said Lofgren. “The President has not released a serious medical evaluation. Just as would be the case if the President were physically unable to execute the office of the President, this resolution urges those entrusted with the responsibility enshrined in the 25th Amendment to employ the services of medical and psychiatric professionals to help in their determination whether the President is mentally capable of carrying out his Constitutional responsibilities.”

Lofgren’s resolution urges the Vice President and Cabinet to “quickly secure the services of medical and psychiatric professionals to examine the President… to determine whether the President suffers from mental disorder or other injury that impairs his abilities and prevents him from discharging his constitutional duties.” 

Section 4 of the 25th Amendment states:

“Whenever the Vice President and a majority of either the principal officers of the executive departments or of such other body as Congress may by law provide, transmit to the President pro tempore of the Senate and the Speaker of the House of Representatives their written declaration that the President is unable to discharge the powers and duties of his office, the Vice President shall immediately assume the powers and duties of the office as Acting President.”

A full copy of the resolution can be found here.

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