7.5.9 Substance misuse in later life

Prevalence and the cohort effect

• Lower intakes can cause harm in later life because of frailty, comorbidity and interacting medicines, so the UK 14-unit weekly low-risk guideline does not guarantee an individual's safety.

• ICD-11 separates episodes of harmful use, harmful patterns of use and dependence.

• Physical dependence on a prescribed medicine does not by itself establish addiction.

• The cohort effect means older cohorts may keep drinking or drug use patterns set earlier in life, which then meet age-related vulnerability.

• English surveys found high recent drinking at ages 55 to 74 and rising lifetime cannabis exposure in older age bands.

• Falling use among younger adults does not mean falling need in older people's services.

Prescribed and purchased medicines

• Review benzodiazepines, z-drugs, opioids, gabapentinoids and over-the-counter products such as codeine compounds and sedating antihistamines.

• Long repeat prescribing can create dependence without deliberate misuse.

• Patients may not regard these medicines as drugs or identify with addiction services.

Early-onset and late-onset problems

Onset pattern guides assessment but does not decide treatment by itself.

Risk factors

• Bereavement, involuntary retirement, pain, insomnia and isolation remove structure and support.

• Previous dependence stays relevant even after long remission.

• Alcohol taken for sleep can worsen later night waking.

• Cognitive impairment leads to forgotten drinks or duplicated doses, and multiple prescribers and accumulated supplies add risk.

Why the ageing body is more vulnerable

• Lorazepam and oxazepam rely more on conjugation, but still need cautious dosing.

• Harms include falls, fractures, delirium, malnutrition, thiamine deficiency, and long-term liver, cardiovascular and neurological disease.

• Sedatives combined with opioids, gabapentinoids or alcohol raise the risk of respiratory depression and overdose.

• Check for duplicated ingredients, especially paracetamol in combination products.

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Presentation

• Older people may present with falls, injuries, confusion, poor sleep, low mood, weight loss, uncontrolled blood pressure, missed appointments or self-neglect, which should prompt enquiry rather than an assumption of misuse.

• Home assessment and collateral history can reveal alcohol deliveries, poorly managed medicines or an empty fridge that a clinic interview misses.

• Age is no reason to think intervention cannot help.

Assessment

• Ask about alcohol, tobacco, illicit drugs, and prescribed and purchased medicines, covering amount, frequency, timing, escalation, benefits and harms.

• Count actual drinks and their strength rather than accepting "a glass".

• Reconcile the prescription list with boxes, discharge records, specialist prescriptions and purchases to find stockpiles, duplicates and who prescribes each drug.

• A low score does not establish safety in someone frail or taking interacting medicines.

• Assess cognition, nutrition, gait, blood pressure, physical complications and suicide risk.

• Withdrawal planning needs daily intake, time since last use, and any previous seizures, delirium tremens or difficult withdrawals.

• Blood tests cover electrolytes, renal and liver function, blood count, glucose and nutritional markers.

• Suspected Wernicke's is treated without waiting for a thiamine result.

• Consider brain imaging after relevant falls, or with focal signs or subacute decline.

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Differential diagnosis

• Reassess cognition after safe reduction: improvement does not exclude dementia, and slow improvement does not prove it.

Withdrawal after admission

Admission can abruptly stop unreported alcohol or benzodiazepine use.

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• Older people may present later or for longer, and infection may coexist.

• Tremor, sweating, tachycardia, hypertension and hallucinations support the diagnosis.

• Persistent delirium during treatment may reflect oversedation.

Management

Brief intervention and withdrawal

• Brief intervention helps older people: personalised feedback, clear advice and shared goals, linking use to consequences without blame.

• Dependent drinkers need a safe withdrawal plan, never abrupt unsupported stopping.

• The threshold for inpatient withdrawal is lower in older people. NICE criteria include more than 30 units a day, or a SADQ score above 30.

• Other NICE criteria are previous withdrawal seizures or delirium tremens, combined alcohol and benzodiazepine withdrawal, or 15 to 30 units a day with significant comorbidity or cognitive impairment.

• Use a monitored, protocol-based benzodiazepine regimen dosed to severity and response; a fixed fraction of a younger adult's dose can undertreat.

• CIWA-Ar relies partly on self-report and orientation, so dementia and delirium distort it; do not escalate on the total alone.

Thiamine

• High-risk patients receive parenteral thiamine prophylaxis.

• Suspected or established Wernicke's is treated with intravenous thiamine 300 to 500 mg three times daily for 3 to 5 days, reviewed daily, then continued parenterally while improvement continues, then orally.

• Correct magnesium, and give thiamine where rare anaphylaxis can be managed.

Relapse prevention

Prescribed dependence-forming medicines

• Agree a gradual reduction plan under NICE NG215, adjusted to symptoms and risk.

• Opioids, benzodiazepines, z-drugs and antidepressants are reduced in proportion to the current dose, so steps get smaller; gabapentinoids usually use fixed decrements.

• New or unusually intense symptoms soon after a reduction suggest withdrawal, but look for other causes.

The original problem and harm reduction

• Offer cognitive behavioural therapy for insomnia, and treat pain, nocturia and sleep disorders.

• Treat pain by its underlying diagnosis rather than substituting routine paracetamol for chronic primary pain.

• If abstinence is not yet achievable, stay in contact and agree safer goals covering nutrition, thiamine, sedative combinations, medication supervision and home hazards.

• Offer naloxone where opioid overdose risk warrants it.

Outcome, safeguarding and capacity

• Some alcohol-related cognitive impairment improves over months of sustained recovery, but Wernicke-Korsakoff syndrome, stroke or head injury can limit recovery.

• In England, Care Act section 42 applies when its three criteria are met; the other UK nations have separate frameworks.

• Substance use or an unwise choice alone does not establish incapacity.

• Assess capacity for the specific decision, when the person is most able, but do not delay an urgent decision to await abstinence.

• Inability to carry out a plan is not the same as incapacity.

Driving

• High-risk features include withdrawal seizures or needing medication-assisted withdrawal.

• Stable opioid substitution treatment may allow licensing under defined conditions, with no universal one-year rule.

• Plan transport alternatives, because isolation can worsen relapse risk.

• A named lead, agreed prescriber and pharmacy, and clear handovers prevent unsafe duplication and loss to follow-up.