3.5.7 Substance Misuse and Other Mental Disorders

Substance Misuse

The prevalence of substance misuse in late life in the UK is relatively low, but there is evidence to suggest that it is increasing. The most commonly misused substances in late life are alcohol and prescription drugs, with benzodiazepines being the most commonly prescribed drug. Clinical features of substance misuse can include physical and cognitive impairment, as well as social and behavioural problems. Differential diagnosis should consider other conditions that can cause similar symptoms, such as depression and dementia.

The aetiology of substance misuse in late life is multifactorial and can include social, psychological, and physical factors. Social factors that can contribute to substance misuse in late life include retirement, bereavement, and social isolation. Psychological factors can include depression, anxiety, and stress, while physical factors can include chronic pain and other medical conditions.

As people age, their tolerance for alcohol decreases, leading to a higher risk of intoxication and negative consequences. Factors contributing to late-onset alcohol issues include female gender, higher socio-economic status, poor physical health, life events, neurotic traits, and psychiatric disorders.

Management strategies for alcohol problems include:

• Positive prognosis if issues stem from practical problems
• Encouraging participation in non-alcohol-related social activities
• Supervising finances in severe cases
• Focusing on reducing physical issues
• Considering residential care to alleviate social isolation

When treating elderly patients for alcohol withdrawal with benzodiazepines (BDZs), caution is needed due to potential cognitive impairment and delirium risks.

Illicit drug abuse is generally not a significant issue among the elderly; however, prescription drug misuse (particularly BDZs, opiates, and analgesics) is more common. Dependence can result from long-term prescriptions for age-related issues like insomnia and arthritis. While doctors may hesitate to discontinue these medications, it’s essential to consider whether withdrawal could improve the patient’s quality of life by reducing chronic side effects such as depression.

Disorder	Substance Use Disorder
Prevalence/Incidence	Relatively low
Clinical Features	Physical and cognitive impairment, social and behavioural problems
Differential Diagnosis	Depression, dementia
Aetiology	Social, psychological, and physical factors
Management	In a multidisciplinary team approach, treatment options may include detoxification, medication, and psychosocial interventions
Prognosis	Positive with appropriate treatment

Other Mental Disorders

Other mental disorders that can occur in late life in the UK include personality disorders, schizophrenia, and somatoform disorders. Clinical features of these disorders can vary, but common symptoms can include changes in mood, behaviour, and perception. Differential diagnosis should consider other conditions that can cause similar symptoms, such as depression and dementia.

Aetiology of other mental disorders in late life:

The aetiology of other mental disorders in late life is not fully understood, but it is thought to be influenced by both genetic and environmental factors. Environmental factors that can contribute to the development of other mental disorders in late life can include social isolation, trauma, and chronic stress.

Management and prognosis of other mental disorders in late life:

Management of other mental disorders in late life should involve a multidisciplinary team, including healthcare professionals, social services, and voluntary organisations. Treatment options may include medication and psychotherapy. The prognosis for other mental disorders in late life can vary depending on the specific disorder and the individual’s response to treatment.

Disorder	Personality disorders	Schizophrenia	Somatoform disorders
Prevalence/Incidence	N/A	0.25-0.64% of the general population	Prevalence varies
Clinical Features	Changes in mood, behaviour, and perception	Changes in mood, behaviour, and perception	Physical symptoms with no identifiable medical cause
Differential Diagnosis	Depression, dementia	Mood disorders, delusional disorder, substance use disorders	Medical conditions, mental health disorders
Aetiology	Genetic and environmental factors	Genetic and environmental factors	Unknown
Management	A multidisciplinary team approach, treatment options may include medication and psychotherapy	Antipsychotic medications, psychotherapy, and supportive care	Psychotherapy, medications, and other treatments as needed
Prognosis	Varies depending on the specific disorder and individual’s response to treatment	Variable, often chronic, with ongoing treatment and management	Varies depending on the specific disorder and individual’s response to treatment

Reference:

1. Beynon, S., Soar, K., & Mitchell, A. J. (2020). Substance misuse in older adults. The Lancet Psychiatry, 7(11), 923-932.
2. Prince, M., Comas-Herrera, A., Knapp, M., Guerchet, M., & Karagiannidou, M. (2016). World Alzheimer Report 2016: Improving healthcare