Dual Diagnosis in Older Adults: Implications for Services

Dual Diagnosis in Older Adults: Implications for Services Adam Searby Case Manager, Caulfield Hospital Mobile Aged Psychiatry Service PhD Candidate, RMIT University, Victoria, Australia

Outline Dual diagnosis in older adults The experience of an inner Melbourne older adult mental health service Bridging The Great Divide Implications for services

Dual diagnosis in older adults Co-occurring mental illness and substance use disorder. A simple term: the reality is a complex number of social and medical factors in addition to a mental illness and drug or alcohol use (Hartz et al, 2014).

Mental Illness Alcohol & Other Drug Use Complex Medical Conditions Social Isolation Stigma of Mental Illness and Substance Use Adaptive Substance Use

Dual diagnosis in older adults Older adults have often been thought to mature out of their substance use (Winick, 1962). Research into older adults and drug and alcohol use indicates a changing ( adaptive ) nature of use: older adults with long drug use careers often adapt their use to substances and levels that their ageing bodies can handle, or easier to obtain in a changing drug world (Levy and Anderson, 2005). Harm reduction NSP, substitution therapy as well as advances in medical treatment are seeing adults with substance use disorders live into old age (AIVL, 2011).

Why does dual diagnosis matter? A core principle of the new Mental Health Act in Victoria is that individuals are able to have their drug and alcohol use addressed (2014). The Victorian Chief Psychiatrist s report into inpatient deaths indicates the involvement of dual diagnosis in a number of cases, often related to absconding and subsequent overdose due to a failure to address withdrawal (2012). Individuals with dual diagnosis have poorer outcomes, higher treatment costs, and a greater risk of psychiatric relapse in addition to the problems associated with long term drug and alcohol use: poverty, marginalisation, stigma and fractured relationships (Minkoff and Cline, 2006; Conner and Rosen, 2008).

You ll be disappointed here. We don t get much substance use at all.

The experience of an Inner Melbourne older adult mental health service A mixed methods study to explore the prevalence of dual diagnosis in the Caulfield Hospital Mobile Aged Psychiatry Service (MAPS). Covering the inner south east metropolitan mental health catchment area, caters specifically to adults 65 and over. Census data (2011) shows a population in this catchment of 265,142. 34,163 are aged 65 and over.

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Prevalence The project involved a file audit of assessments conducted by MAPS clinicians over the past two years (June 2012-14: N=593). Completed file auditing shows a prevalence of 15.5% dual diagnosis in MAPS in real terms, this is 92 individuals over a two year period. However, there is no screening tool and interpretations of problematic alcohol or drug use are poor particularly in relation to Commonwealth Government alcohol guidelines.

Cannabis and Benzodiazepines Benzodiazepines and Opiates Alcohol, Benzodiazepines and Others Alcohol and Opiates Cannabis None recorded Alcohol and Cannabis Alcohol, Cannabis and Other Opiates Substances Recorded Alcohol and Benzodiazepines Benzodiazepines Alcohol 60 55 50 45 40 35 30 25 20 15 10 5 0 Gender Male Female Consumers

Eating Disorder Personality Disorder Schizoaffective Disorder Bipolar Affective Disorder Schizophrenia Mental State for Assessment (Undefined) Primary Diagnosis Depression Behavioural and Psychological Symptoms of Dementia 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0 Dual diagnosis Yes No Consumers

For lovers of stats Significant association between gender and AOD use (x 2 (1) = 19.21, p=<0.001). OR of male AOD use 5.45 times higher than females. Dual diagnosis group also younger (mean 72.82) than those who did not use AOD (mean 79.24), (-6.629, 95% CI [-8.340, -4.508], p=<0.001). Significant association between gender and substance preference males recorded predominantly alcohol use, females spread between polysubstance, benzodiazepine and opiate use as well as alcohol (41, p=<0.001).

The Great Divide Comorbid mental health problems are often present in older adults who use alcohol and other drugs (Bartels et al, 2006; Lofwall et al, 2005; Coulson et al, 2014). Collaboration between older adult mental health services and AOD treatment teams is essential due to the complexities inherent in dual diagnosis presentations.

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Implications for services 1. Collaboration and expansion to primary care and hospital settings 2. Harm reduction 3. Enhanced assessment 4. Treatment settings

Collaboration and expansion to primary care and hospital settings Many older adults with AOD problems/dual diagnosis may not present via traditional means. Stigma has shown to deter help seeking, more so when mental health problems are involved (Conner and Rosen, 2008). Incidental finding of AOD use during times of hospitalisation requires collaborative referral pathways.

Harm reduction Harm reduction is largely geared towards the dangers inherent in injecting drug use (Ball, 2007). However, harm reduction in older adults needs to address different issues (Searby, Maude and McGrath, 2015, in press): Drink driving Prescription medication misuse Cumulative AOD use and cognitive impairment Physical risks, such as falls and health complications Vulnerability

Enhanced assessment Older adults with dual diagnosis are a hidden population. A 1995 study found only 1% of elderly women with substance use disorders were correctly identified by assessing physicians (Dufour and Miller). Badrakalimuthu, Rumball and Wagle s 2005 audit found 60% of older adults admitted to an acute psychiatric unit had no documentation regarding their drug and alcohol history. Blixen, McDougall and Suen s 2007 study of 101 adults 65 and over discharged from psychiatric hospitals in the US found 38 (37.6%) had a comorbid substance use disorder.

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Enhanced assessment Screening and assessment of AOD use needs to consider co-occurring mental health problems, and vice versa. Screening needs to be intuitive to respond to presentations that may be different to younger consumers of AOD and mental health services (Schonfield, 2010). All older adults should be screened, without exception.

Treatment settings I don t want to go to detox. I ve heard that it is full of ice addicts and I ve read that they re violent.

Treatment settings Current treatment settings are ill-equipped to manage the complex presentations of older adults who use AOD, more so those with dual diagnosis (Hunter et al, 2010). There is a need to offer specialised treatment services to this cohort. Embedded AOD services, working closely with or within older adult mental health services, may provide better integrated care with more successful treatment outcomes (Levkoff, 2004).

Thank you Contact: Adam Searby a.searby@alfred.org.au Caulfield Hospital MAPS 240 Kooyong Road Caulfield Melbourne Victoria Australia