Mohammed T. Abou-Saleh

DRUG MISUSE 617benzodiazepine and a gradual reduction in dosage over the courseof months is advisable. Rapid detoxification is associated withbreakthrough withdrawal symptoms and may be complicated byconvulsions. If a rapid withdrawal is necessary, it is bestconducted in an inpatient setting if severe dependency issuspected. As with alcohol, the withdrawal period for the elderlyis more likely to be complicated by confusion than in youngeradults.In cases where abstinence is not achievable or desirable, aminimization of dose and adoption of a non-daily pattern of useare reasonable targets. Psychological techniques, such as relaxationtraining and educative initiatives in the areas of sleep hygieneand correct medication use, may also prove valuable. Cormack 81demonstrated that writing to benzodiazepine users in primary careurging them to reduce their medication use resulted in a fall intotal use by one-third over the next 6 months.Treatment of other forms of drug misuse in the elderly is underresearched.Anticipation of problems and safe prescribing remainparamount in treatment and prevention. Misuse of analgesics mayrequire formal detoxification if opioids are involved or physicaldependence has developed. More often the patient requiresinformation to allow him/her to make an informed choice aboutdrug use and an alternative form of treatment for his/hercondition. Still less information is available on the treatment ofillicit drug use in the elderly. At present there is no evidence tosuggest that an approach other than that used for younger adultsshould be adopted, although adaptations of such treatmentsshould involve lower doses of medication and the adoption of aless directly confrontational approach.PSYCHOLOGICAL INTERVENTIONSOnce a patient is detoxified, rehabilitation is necessary to addressthe issues behind his/her substance use and to foster copingstrategies for the future. Few studies have examined the particularneeds of the elderly in a rehabilitation setting. Janik and Dunhamreport on comparative outcomes for over 3000 over-60-year-oldsand younger entrants into alcohol treatment programmes 82 .Outcome measured in terms of alcohol intake, therapist assessmentand alcohol problems after 6 months showed no differencesbetween the groups.Outcomes from programmes designed specifically with theelderly in mind may be more appropriate for consideration.Some success has been claimed for models encouraging thedevelopment of social networks with self-management skills 83 .Kofoed 84 , in a small study, reported that retention in outpatienttreatment of older adults was greater in an age-specific treatmentgroup that focused on socialization and minimal confrontation (amainstay of many programmes), compared with older patients in amixed-age treatment group. At 1 year follow-up the effect was lost.Variations of the Alcoholics Anonymous 12-step model tailored tothe needs of elders have been reported upon 85 in the USA, withvarying degrees of success. Models low on confrontation,traditionally regarded as fundamental to overcoming denial onthe part of the patient, appear to be supported by the work ofKashner 86 , who found that 1 year follow-up of elders in aconfrontational programme revealed half the levels of abstinenceas compared with a group in a programme where self-esteem,tolerance and peer relationships were promoted. Behaviouralapproaches, including cue identification and avoidance, have alsobeen reported to be of clinical benefit 83 . A programme focusing oncognitive techniques, such as cognitive restructuring, assertiontraining and self-monitoring of drinking, resulted in 75% of thosecompleting the programme sticking to their treatment goals at1 year follow-up. The evidence suggests that a range of therapeutictechniques may be beneficial for the elderly and that localprovision may depend upon the skills available to the treatingagency. It is suggested that even if an elder’s only therapeuticprogramme is not available, a better therapeutic outcome mayoccur from a more homogeneous group, where the opportunity foridentification and vicarious learning is enhanced.The above studies all relate to the outcome of alcohol treatmentprogrammes. Even less age-specific studies are available to guidethe clinician in the provision of aftercare to the elderly nonalcoholicdrug user. An avoidance of drugs that have adependence potential is advisable if practical. Adequate rehabilitationand continuing support of the individual are indicated.This may be provided through generic old age psychiatry servicesor through specialist drug services, depending upon which serviceappears best able to cater for the specific needs of the user. Thechoice of service provider should reflect the lifestyle of the patient,as opposed to being a decision based solely on chronological asopposed to biological age. Further services may also be availablein the form of mutual support groups similar to those availablefor alcohol. The adoption of a cognitively-based programme lowon confrontation and designed to foster strong social supportappears optimal, as shown in work in the field of alcohol.ConclusionSubstance misuse and old age psychiatry have long beenunpopular choices for specialization. Both fields are known forproviding challenging patients with differing priorities to those ofthe clinician. Research in either field is hampered by the difficultyin obtaining reliable clinical data on conditions for which fewempirical measures exist. The field of old age substance misuse hassuffered to some extent in clinical practice, where patients do notfit neatly into either service and welcomed by neither.It is, however, clear that there exists a significant morbidity dueto drug use in the elderly. The problem may be iatrogenic andautogenic in origin. Increased life expectancy and the cohort effectof generations of recreational drug users reaching old age arelikely to intensify the problem. Adequate research to identify atriskindividuals and the provision of appropriate and accessibletreatment services for the elderly drug misuser remain one of themajor challenges to health care providers at the start of the newmillennium.REFERENCES1. Patterson TL, Jeste DV. The potential impact of the baby-boomgeneration on substance abuse among elderly persons. Psychiat Serv1999; 50: 1184–8.2. Grimley-Evans J. Geriatric medicine (geriatrics). In Walton J,Barondess JA, Lock S, eds, The Oxford Medical Companion. Oxford:Oxford University Press, 1994: 321–6.3. Murphy JT, Harwood A, Gotz M, House AO. Prescribing alcohol in ageneral hospital: not everything in black and white makes sense.J R Coll Physicians Lond 1998; 32: 358–9.4. Pascarelli EF. Drug abuse and the elderly. In Lowinson JH, Ruiz P,eds, Substance Abuse: Clinical Problems and Perspectives. Baltimore,MD: Williams and Wilkins 1981: 752–7.5. Breeze J. Hollister impression. Br J Nurs 1993; 3: 905–8.6. Blenkiron P. The elderly and their medication: understandingcompliance in family practice. Postgrad Med 1996; 72: 671–6.7. Eisdorfer C, Basen MB. Drug misuse in the elderly. In Dupont RL,Goldstein A, O’Donnell J, eds, Handbook on Drug Abuse. Washington,DC: National Institute on Drug Abuse, 1979: 271–6.8. United Nations International Drug Control Programme. World DrugReport. Oxford: Oxford University Press, 1997: 9–14.9. World Health Organization. The ICD-10 Classification of Mental andBehavioural Disorders. Geneva: WHO, 1992: 75–7.