Substance Use and Older People E-Book

Ilana Crome

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Addiction Press
• Sprache: Englisch

Seitenzahl: 863

Veröffentlichungsjahr: 2014

Beschreibung

Substance use and addiction is an increasing problem amongst older people. The identification of this problem is often more difficult in older patients and is frequently missed, particularly in the primary care context and in emergency departments, but also in a range of medical and psychiatric specialties.

Substance Use and Older People shows how to recognise and treat substance problems in older patients. However, it goes well beyond assessment and diagnosis by incorporating up-to-date evidence on the management of those older people who are presenting with chronic complex disorders, which result from the problematic use of alcohol, inappropriate prescribed or over the counter medications, tobacco, or other drugs. It also examines a variety of biological and psychosocial approaches to the understanding of these issues in the older population and offers recommendations for policy.

Substance Use and Older People is a valuable resource for geriatricians, old age psychiatrists, addiction psychiatrists, primary care physicians, and gerontologists as well as policy makers, researchers, and educators. It is also relevant for residents and fellows training in geriatrics or geri-psychiatry, general practitioners and nursing home physicians.

Leseprobe

CONTENTS

COVER

SERIES PAGE

TITLE PAGE

COPYRIGHT PAGE

DEDICATION

CONTRIBUTORS

FOREWORD

INTRODUCTION

References

LIST OF ABBREVIATIONS

Section 1: LEGAL AND ETHICAL ASPECTS OF CARE FOR OLDER PEOPLE WITH SUBSTANCE MISUSE

Chapter 1: NEGOTIATING CAPACITY AND CONSENT IN SUBSTANCE MISUSE

Introduction

Capacity and unwise decisions

Consent, barriers to decision making and substituted decision making

Conclusion

References

Chapter 2: ELDER ABUSE

Introduction

Defining elder abuse

Main reviews

The effects of elder abuse

Discussion

Conclusions and next steps

References

Chapter 3: THE UNITED STATES PERSPECTIVE

The ageing of the baby boomers and its impact on substance abuse

Ethical and legal aspects of substance misuse in older adults

Conclusion

References

Chapter 4: THE EUROPEAN PERSPECTIVE

Introduction

Use and possession

Crime

European Convention of Human Rights

Delivering services for the elderly with substance misuse – ethical aspects

Research and development

Policy making

Some differences between Europe and the USA

Ethical issues regarding treatment

Stigma

Underprescribing controlled drugs

Summary

References

Chapter 5: CLINICAL MEDICINE AND SUBSTANCE MISUSE

Introduction

Why is clinical medicine important?

Challenges for the future

Conclusions

References

Section 2: EPIDEMIOLOGY AND DEMOGRAPHY

Chapter 6: CIGARETTE SMOKING AMONG ADULTS AGED 45 AND OLDER IN THE UNITED STATES, 2002–2011

Introduction

Evaluation methodology

Results

Discussion

Conclusion

References

Chapter 7: EPIDEMIOLOGY AND DEMOGRAPHY OF ALCOHOL AND THE OLDER PERSON

Introduction

Main reviews

Discussion

Conclusions and next steps

References

Chapter 8: EPIDEMIOLOGY AND DEMOGRAPHY OF ILLICIT DRUG USE AND DRUG USE DISORDERS AMONG ADULTS AGED 50 AND OLDER

Introduction

Survey studies

Studies of treatment-seeking or clinical patients

Health implications

Discussion

Next steps

References

Chapter 9: EPIDEMIOLOGY AND DEMOGRAPHY OF NONMEDICAL PRESCRIPTION DRUG USE

Introduction

Findings

Discussion

Conclusions

Acknowledgement

References

Section 3: LONGITUDINAL STUDIES OF AGEING AND SUBSTANCE ABUSE

Chapter 10: AGEING AND THE DEVELOPMENT OF ALCOHOL USE AND MISUSE

Background

Results

Discussion

Conclusions

References

Chapter 11: PROGRESSION FROM SUBSTANCE USE TO THE DEVELOPMENT OF SUBSTANCE USE DISORDERS

Introduction

Substance use progression process

Risk factors influencing substance use progression

Future direction

Conclusions

Acknowledgement

References

Chapter 12 : PSYCHOPHARMACOLOGY AND THE CONSEQUENCES OF ALCOHOL AND DRUG INTERACTIONS

The extent of alcohol and drug misuse among older adults

Psychopharmacology of alcohol and drug misuse in older people

Alcohol–drug interactions in older adults

Clinical presentation and evaluation of substance use disorders in the elderly

Conclusions

References

Section 4: COMPREHENSIVE GERIATRIC ASSESSMENT AND SPECIAL NEEDS OF OLDER PEOPLE

Chapter 13: COMPREHENSIVE GERIATRIC ASSESSMENT AND THE SPECIAL NEEDS OF OLDER PEOPLE

Background

Assessment

Case presentations

Discussion

Conclusion

References

Section 5: SCREENING AND INTERVENTION IN HEALTH CARE SETTINGS

Chapter 14: SCREENING AND BRIEF INTERVENTION IN THE PSYCHIATRIC SETTING

Overview

Screening and assessment for alcohol use disorders

Illicit drugs

Prescription drug abuse

Brief intervention for alcohol, prescription drug abuse and illegal drug use

Summary

References

Chapter 15: TOBACCO USE CESSATION

Introduction

Smoking cessation interventions among older adults

Counselling and behavioural interventions

Physician-delivered interventions

Other interventions

Conclusions

References

Section 6: USE OF SUBSTANCE ABUSE TREATMENT SERVICES AMONG OLDER ADULTS

Chapter 16 : EPIDEMIOLOGY OF USE OF TREATMENT SERVICES FOR SUBSTANCE USE PROBLEMS

Introduction

Tobacco cessation service use and characteristics

Alcohol treatment use and characteristics

Trend in substance abuse treatment admissions

Drug abuse treatment use and outcomes

Substance abuse treatment in general health care settings

Discussion and conclusion

References

Chapter 17: IMPLICATIONS FOR PRIMARY CARE

Background

Implications for primary care

Different populations at risk

Screening in primary care

Scale of benefit

Co-morbidities and social context

Conclusions

References

Chapter 18: ADDICTION LIAISON SERVICES

Introduction

Organizing an addiction liaison service to a general hospital

Case vignette 1

Addiction liaison services for older adults

Essential elements of liaison service provision for older adults

Screening for alcohol problems in older adults

Screening for drug use problems

Case vignette 2

Summary

References

Chapter 19: CURRENT HEALTHCARE MODELS AND CLINICAL PRACTICES

Introduction

An ageing population

Service development and provision

Integrated care and workforce development

Conclusions and recommendations

References

Section 7: AGE-SPECIFIC TREATMENT INTERVENTIONS AND OUTCOMES

Chapter 20: PHARMACOLOGICAL AND INTEGRATED TREATMENTS IN OLDER ADULTS WITH SUBSTANCE USE DISORDERS

Introduction

Tobacco

Alcohol

Opioids

Benzodiazepines

Other substances of abuse

Integrated treatments

Conclusion and future directions

References

Chapter 21: THE ASSESSMENT AND PREVENTION OF POTENTIALLY INAPPROPRIATE PRESCRIBING

Introduction

Inappropriate psychotropic use in elderly patients

Implicit IP criteria

Explicit IP criteria

Applying STOPP/START criteria as an intervention

Other methods of detection and prevention of IP in older people

Conclusions

References

Chapter 22: AGE-SENSITIVE PSYCHOSOCIAL TREATMENT FOR OLDER ADULTS WITH SUBSTANCE ABUSE

Introduction

Seven characteristics of age-sensitive treatment

2 – Flexible

Six components of age-sensitive psychosocial treatment

Age-segregated or mixed-age treatment

Future directions

Acknowledgements

References

Chapter 23: INTEGRATED TREATMENT MODELS FOR CO-MORBID DISORDERS

Introduction

Methodological approach to examining SMCD in older people

Future direction and challenges

References

Section 8: POLICY: PROPOSALS FOR DEVELOPMENT

Chapter 24: PROPOSALS FOR POLICY DEVELOPMENT

Introduction

Recognition of a need or problem and arguments made to justify the development of policy

Policy options

Policy design and implementation

Conclusion

References

Chapter 25: PROPOSALS FOR ALCOHOL-RELATED POLICY DEVELOPMENT IN THE UNITED STATES

Recommended low-risk alcohol consumption levels

Traffic crash risks among the elderly

Driving policy questions

Factors to consider when contemplating legal policies

Summary and conclusions

References

Chapter 26: PROPOSALS FOR POLICY DEVELOPMENT

Introduction

Past and present approaches to reduce tobacco consumption

Phase three anti-tobacco efforts

Recent anti-tobacco proposals

Policy proposals to further reduce tobacco prevalence

References

Chapter 27: RECOMMENDATIONS

Background

Epidemiology

Clinical presentations

Education and training

Who gets treatment – treatment interventions

Concluding remarks

INDEX

END USER LICENSE AGREEMENT

List of Tables

Chapter 03

Table 3.1 Elements of decisional capacity with clinical examples

Chapter 06

Table 6.1 Overall characteristics of US adults aged 45 years or older (US National Health Interview Survey, 2002 and 2011)

Table 6.2 Current cigarette smoking among US adults aged 45 years or older by selected sociodemographic characteristics (US National Health Interview Survey, 2002 and 2011)

Table 6.3 Adjusted odds ratios (AOR) of correlates of current cigarette smoking among US adults aged 45 years or older by age strata and by year (US National Health Interview Survey, 2002 and 2011)

Chapter 07

Table 7.1 Various criteria for heavy, hazardous or at-risk drinking

Chapter 08

Table 8.1 Studies of illicit drug use

Chapter 09

Table 9.1 Characteristics of past-year users aged 50 and older: NSDUH 2011 [9]

Table 9.2 Characteristics of emergency department patients aged 55 and over: DAWN 2010 [11]

Table 9.3 Characteristics of treatment admissions aged 55 and older: TEDS 2010 [14]

Table 9.4 Drug poisoning deaths per 100 000 aged 55–64: CDC 2010 [13]

Chapter 10

Table 10.1 Drinking patterns by sex and World Health Organization region (all ages)

Chapter 11

Table 11.1 Influences on substance use and the progression of substance use to disorders

Table 11.2 Typical symptoms of drug use progression among the elderly

Chapter 12

Table 12.1 Physical and psychiatric symptoms or signs that trigger evaluation for substance use disorders in the elderly

Table 12.2 Clinical evaluation of substance use disorders in the elderly

Chapter 13

Table 13.1 Diagnostic and statistical manual criteria for substance use disorder (SUD)

Chapter 15

Table 15.1 Multimodal interventions for older smokers: A review of randomized trials

Chapter 16

Table 16.1 Prevalences of substance use among older adults in the United States

Table 16.2 Studies of tobacco treatment among older adults

Table 16.3 Studies of alcohol treatment use among older adults

Table 16.4 Studies of alcohol and drug abuse treatment use among older adults

Chapter 21

Table 21.1 Prevalence rates of potentially inappropriate medications (PIMs) in older patient groups in various clinical settings according to STOPP criteria and Beers [2]

Table 21.2 Prevalence rates of potential prescribing omissions (PPOs) in older patient groups in various clinical settings [2]

Table 21.3 Results of a randomized controlled trial (Figure 21.2) comparing the adverse drug reaction (ADR) rates in older people with acute illness receiving either standard pharmaceutical care (control) or adjustment of their medication according to STOPP/START criteria advice offered to their attending doctors at a single time point early in the index hospitalization (intervention) [38]

Chapter 26

Table 26.1 Overview of four phases of tobacco control in the United States from 1950 to 2013

Table 26.2 Phases of litigation against the tobacco industry from 1954 to 2013

List of Illustrations

Chapter 06

Figure 6.1 Ten-year trends in the proportion (%) of US adults aged 45–64 years and 65+ years (US National Health Interview Survey, 2002–2011).

Figure 6.2 Ten-year trends in current cigarette smoking prevalence (%) among US adults aged 45–64 years and ≥65 years (US National Health Interview Survey, 2002–2011).

Figure 6.3 Ten-year trends in ‘some day' and ‘everyday' cigarette smoking prevalence (%) in the past month among US adults aged 45–64 years and 65+ years (US National Health Interview Survey, 2002–2011).

Chapter 07

Figure 7.1 Any alcohol use in the past 30 days: US population all ages.

Figure 7.2 Average number of drinks per day for age groups compared to the CDC heavy drinking criterion.

Figure 7.3 Percentage of men and women aged 65 or older who within the last 30 days drank more than the indicated number of drinks per day.

Chapter 09

Figure 9.1 Lifetime, past-year and past-month nonmedical use of pain relievers: NSDUH 2011 [1]. Notes : Nonmedical use is defined as use of a medication without a prescription belonging to the respondent or use that occurred simply for the experience or feeling the drug caused. Pain relievers include hydrocodone, methadone, morphine, oxycodone, tramadol and similar drugs.

Figure 9.2 Change in rates for emergency department patients: DAWN 2004–2011 [9].

Figure 9.3 Proportion of treatment admissions aged 45 and over with primary problems with other opiates and synthetics: TEDS 1992–2010 [13]. Note : Other opiates and synthetics include buprenorphine, codeine, hydrocodone, hydromorphone, meperidine, morphine, opium, oxycodone, pentazocine, propoxyphene, tramadol and any other drug with morphine-like effects.

Figure 9.4 Drug poisoning death rates by age: United States, 1999–2010 [17].

Figure 9.5 Drug poisoning death rates by age group: NCHS 2010 [13]. Note : The International Classification of Diseases-10 definition of natural and semi-synthetic opioid analgesics includes morphine, oxycodone, and hydrocodone. Synthetic opioid analgesics include fentanyl.

Chapter 11

Figure 11.1 Psychoactive substance use spectrum.

Figure 11.2 Framework of progression from substance use to substance use disorders.

Chapter 21

Figure 21.1a Effect of application of STOPP criteria within 48 hours of acute hospital admission (intervention) on medication appropriateness (MAI score) in older patients compared to normal pharmaceutical care (control). The highly significant improvement in group mean MAI score in the intervention group was rapid and was maintained to the end of a six-month follow-up interval (medication appropriateness improves as MAI score decreases) [37].

Figure 21.1b Effect of application of START criteria shortly after hospital admission in acutely ill older people. Over one-third of patients had at least one potential prescribing omission according to Assessment of Underutilization of Medication (AUM) criteria. After application of START criteria, the inappropriate underutilization of medication rate in the intervention group fell to under 3%; this beneficial effect was maintained to the end of six-months' follow-up [37].

Figure 21.2 Schematic diagram of a randomized controlled trial of STOPP/START criteria as an intervention in older people who are hospitalized with acute unselected illness. The aim was to determine if application of STOPP/START criteria at a single time point early in the hospital stay could significantly attenuate adverse drug reactions (ADRs) during the index hospitalization.

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Addiction Press aims to communicate current ideas and evidence in this expanding field, not only to researchers and practising health professionals, but also to policy makers, students and interested non-specialists. These publications are designed to address the significant challenges that addiction presents to modern society.

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Substance Use and Older People

Edited by

Ilana Crome, MA MD MPhil FRCPsych

Li-Tzy Wu, ScD MA

Rahul (Tony) Rao, MD MSc FRCPsych

Peter Crome, MD PhD DSc FRCP FFPM FBPharmacolS

This edition first published 2015 © 2015 by John Wiley & Sons, Ltd

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Library of Congress Cataloging-in-Publication Data

Substance use and older people / edited by Ilana Crome, Li-Tzy Wu, Rahul (Tony) Rao, Peter Crome.  p. ; cm. Includes bibliographical references and index.

 ISBN 978-1-119-97538-0 (cloth)I. Crome, Ilana B., editor. II. Wu, Li-Tzy., editor. III. Crome, Peter, editor. IV. Rao, Rahul, editor.[DNLM: 1. Substance-Related Disorders. 2. Aged. 3. Middle Aged. WM 270] HV5824.A33 362.29084′9–dc23

   2014020561

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

This book is dedicated to our families – past, present and future.

CONTRIBUTORS

Marja Aartsen, PhDAssistant Professor Sociology and Social Gerontology, Faculty of Social Sciences, VU University Amsterdam, Amsterdam, The Netherlands

Mohammed Abou-Saleh, MPhil FRCPsychProfessor of Psychiatry, St George's, University of London, London, UK

Stephan Arndt, PhDDirector, Iowa Consortium for Substance Abuse Research; Professor, Departments of Psychiatry and Biostatistics, University of Iowa, Iowa City, IA, USA

Amit Arora, MD FRCP MScConsultant Physician and Geriatrician, University Hospital of North Staffordshire, Stoke-on-Trent, UK; Honorary Clinical Lecturer, Keele University, Keele, UK

Roger Bloor, MD MPsyMed FRCPsych Cert Med EdConsultant in Addiction Psychiatry, North Staffordshire Combined Healthcare NHS Trust, Teaching Fellow, School of Medicine, Keele University, Keele, UK

Kathleen T. Brady, MD PhDAssociate Provost of Clinical and Translational Research, and Director of South Carolina Clinical and Translational Research Institute, Medical University of South Carolina, Charleston, SC, USA

Penny L. Brennan, PhDResearch Health Science Specialist, Center for Health Care Evaluation, Veterans Affairs Palo Alto Health Care System, Menlo Park CA, USA

Shawna L. Carroll Chapman, PhDPostdoctoral Researcher, Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA

Devoshree Chatterjee, MRCGPDepartment of Primary Care & Population Health, University College London, London, UK

Marion Coe, BAIntramural Research Training Award Fellow, Section on Human Psychopharmacology, Laboratory of Clinical and Translational Studies, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA

Ilana B. Crome, MA MD MPhil FRCPsychSenior Research Fellow, Imperial College, London, UKEmeritus Professor of Addiction Psychiatry, Keele University, Keele, UKHonorary Consultant Psychiatrist, South Staffordshire and Shropshire Healthcare NHS Foundation Trust, Stafford, UKHonorary Professor, Queen Mary University of London, London, UK

Peter Crome, MD PhD DSc FRCP FFPM FBPharmacolSHonorary Professor, Department of Primary Care and Population Health, University College London, London, UKEmeritus Professor of Geriatric Medicine, Keele University, Keele, UK

Shanta R. Dube, PhD MPHAssociate Professor, Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, GA, USA

Michael Fleming, MD MPHProfessor, Department of Psychiatry and Family Medicine, Northwestern University, Chicago, IL, USA

Cynthia M.A. Geppert, MD MA PhD MPH MSBEChief, Consultation Psychiatry and Ethics, New Mexico Veterans Affairs Health Care System, Albuquerque, NM, USAAssociate Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine, Albuquerque, NM, USA

Michael Givel, PhDProfessor, Department of Political Science, The University of Oklahoma, Norman, OK, USA

Kerry M. Green, PhDAssistant Professor, Department of Behavioral and Community Health, University of Maryland School of Public Health, College Park, MD, USA

Ralph Hingson, ScD MPHDirector, Division of Epidemiology and Prevention Research, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA

Steve Iliffe, FRCGPProfessor of Primary Care for Older People, Department of Primary Care & Population Health, University College London, London, UK

Stephen Jackson, MD FRCPProfessor of Clinical Gerontology, King's College Hospital, London, UK

Jonathan C. Lee, MDAssociate Medical Director, The Farley Center at Williamsburg Place, Williamsburg, VA, USAAssistant Professor, Department of Psychiatric Medicine, Brody School of Medicine, East Carolina University, NC, UK

Sonne Lemke, PhDHealth Science Specialist, Program Evaluation and Resource Center, Department of Veteran Affairs, Menlo Park, CA, USA

Ting-Kai Li, MDProfessor, Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA

Susanne MacGregor, MA PhD FRSA FAcSSProfessor of Social Policy, Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, University of London, London, UK

Paolo Mannelli, MDAssociate Professor, Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA

Jill Manthorpe, MAProfessor of Social Work, Director of the Social Care Workforce Research Unit, King's College London, London, UK

Finbarr C. Martin, MD MSc FRCP FCSTConsultant Geriatrician at Guys & St Thomas' NHS Foundation Trust, London, UKHonorary Professor of Medical Gerontology, King's College London, London, UK

Jane Carlisle Maxwell, PhDSenior Research Scientist, Addiction Research Institute, Center for Social Work Research, The University of Texas at Austin, Austin, TX, USA

Maitreyee Mohanty, PhDPharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA

Rudolf H. Moos, PhDProfessor Emeritus, Stanford University; Center for Health Care Evaluation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA

Denis O'Mahony, MD FRCPI FRCPDepartment of Medicine (Geriatrics),University College Cork, Cork, Ireland

Andrew O'Neill, MB BaO BCh MRCPSpecialist Registrar in Geriatric Medicine, University Hospital of North Staffordshire, Stoke-on-Trent, UK

Ashwin A. Patkar, MD MRC PsychProfessor, Department of Psychiatry and Behavioral Sciences, Department of Community and Family Medicine, Medical Director, Duke Addiction Programs & Center for Addictive Behavior and Change, School of Medicine, Duke University Medical Center, Durham, NC, USA

Daniel J. Pilowsky, MD MPHAssistant Professor of Clinical Epidemiology and Psychiatry, Department of Epidemiology, Mailman School of Public Health; and Department of Psychiatry, Columbia College of Physicians and Surgeons, Columbia University, New York, NY, USA

Vijay A. Ramchandani, PhDInvestigator and Chief, Section on Human Psychopharmacology, Laboratory of Clinical and Translational Studies, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA

Rahul (Tony) Rao, MD MSc FRCPsychVisiting Researcher, Department of Old Age Psychiatry, Institute of Psychiatry, London, UK and Lead for Dual Diagnosis, Mental Health of Older Adults and Dementia Clinical Academic Group, South London and Maudsley NHS Foundation Trust, UK

Kritika Samsi, MSc PhDResearch Fellow, Social Care Workforce Research Unit, King's College London, UK

Abdi Sanati, MD MSc MRCPsychConsultant psychiatrist, North East London NHS Foundation Trust, London, UK

Susan K. Schultz, MDProfessor, University of Iowa College of Medicine, Iowa City, IA, USA

Kathleen Schutte, PhDResearch Health Science Specialist, Center for Health Care Evaluation, Veterans Affairs Palo Alto Health Care System, Menlo Park CA, USA

M. Shafi Siddiqui, MDLinden Oaks Medical Group, Naperville, IL, USA

Patricia W. Slattum, PharmD PhDDirector, Geriatric Pharmacotherapy Program, Professor of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA

Carla L. Storr, MPH ScDProfessor, Department of Family & Community Health, University of Maryland School of Nursing, Baltimore, MD, USA

Peter J. Taylor, DO MAConsulting GeropsychiatristNew Mexico Veterans Affairs Health Care System, Albuquerque, New Mexico, USA

Derrett Watts, MBBCh DRCOG MRCPsych MPhilConsultant Psychiatrist – Substance Misuse, North Staffordshire Combined Healthcare NHS Trust, Stoke-on-Trent, UK

Dan Wilson, MB BChir MRCPDepartment of Clinical Gerontology, King's College Hospital NHS Foundation Trust, London, UK

Li-Tzy Wu, ScD MAProfessor of Psychiatry, Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA

FOREWORD

This edited volume by Drs. Crome, Wu, Rao and Crome, Substance Use and Older People, arrives at just the right moment. To my knowledge this is the first book devoted to substance use disorders in older adults. And the substances include alcohol, illicit drugs and tobacco use, all challenges to the well-being of the elderly. Focus upon substance misuse has become increasingly timely, for the numbers of older adults will increase dramatically with the aging of the baby boomer generation (what some have called the grey tsunami). In addition, the relatively heavier burden of substance misuse in middle aged cohorts compared to older cohorts suggests that the burden will be even greater than simply projected by the increased number of elders. Not only is this volume timely, the chapters are comprehensive, in depth and they cover a range of critical topics, from psychopharmacology to the legal and ethical issues associated with substance misuse in this population. The multinational focus is also welcomed as concentration on one country, even one continent, will underestimate the valuable data which is emerging worldwide and which can inform clinical practice.

I recently chaired an Institute of Medicine (IOM) committee that produced the report, The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? (National Academies Press, Washington, DC, 2012). Our original charge was to explore the workforce needs for mental health problems in the elderly, yet within one hour of our first meeting the committee identified substance use disorders of enough importance that it received equal billing in our report. The demographic and epidemiological data presented in this volume clearly document the presence of problems, such as binge drinking of alcohol, that are already of public health significance among older adults. In addition, middle-aged cohorts carry a much higher burden than elders of substance misuse that cuts cross a variety of problems, from nonprescription use of prescription medications to use of illegal substances such as heroin and cocaine. We have not accumulated data to date that documents that this burden will persist as the middle aged enter late life. Nevertheless, past history and common sense suggests that we will face a higher burden clinically in the future among the elderly than we face today. And according to the IOM report, we do not have a workforce, both professional and volunteer, to meet the needs of these elders. To prepare investigators and practitioners to fill the emerging workforce need, this volume will be especially valuable as a basic text and ready reference for this workforce.

Substance use disorders and their functional as well as social limitations are complex and typically occur with other health problems. They often go unnoticed in large part because they are not viewed by health-care professionals and family as important enough to explore in clinical or even personal family communications. We do not wish to consider that our parents and grandparents, who we may have revered during our earlier lives, may suffer from an embarrassing problem that we typically identify with adolescents or young adults. If we are guilty of this oversight, we either consciously or inadvertently cover over substance misuse and, subsequently, the problems worsen and the older adult suffers. The chapter on elder abuse highlights that abuse may take the form of neglect of obvious problems and discouragement in seeking proper care.

Recent analyses of extant data focusing on the elderly, especially the National Survey of Drug Use and Health (NSDUH), has documented over the past ten years the burden in the elderly, a burden that was not well studied in past epidemiological studies. To put this another way, if we need solid numbers to back up our claim that substance use is a major public health problem among the elderly, the numbers are there! Chapters on epidemiology and demography within this text provide easy access for readers, especially valuable if readers are in a position to influence policy at local, state and federal levels.

The next section of the book focuses upon multidisciplinary approaches to substance misuse in the elderly. Treating substance use disorders at all ages, but especially in the elderly, requires a team. And that team may consist of members not usually associated with treatment at earlier ages, namely practitioners from clinical medicine. Older persons are vulnerable to a ‘cascade effect' if they suffer from significant and ongoing problems in one area of health. For example, an older adult may have abused alcohol for many years and now encounters medical complications, such as liver disease. Yet another older person may suffer from low back pain and then begin to abuse opioid analgesics. Rarely can one specialist adequately treat substance misuse in isolation. This volume provides a framework for multidisciplinary as well as interdisciplinary approaches to care. I would propose that professionals treating older adults with substance use disorders may actually need transdisciplinary care, namely care from professionals who have skills which cross disciplines, such as substance use counselling, medical care of co-morbid problems and the effective use of psychotropic medications. That is, care of this population may benefit from a new type of professional in the future.

Treatment of substance use disorders across the life cycle is difficult, with few approaches leading to consistently dramatic improvements which persist through time. The authors of chapters on treatment and the system of health care focused on late life substance misuse recognize these challenges and provide useful guides for better treatment today and into the future. I would propose, however, that our knowledge base for effective treatment is incredibly limited for the elderly and we need much more research to inform our treatments. This volume provides a useful catalogue and description of current evidence-based as well as traditional treatments from which future treatments can evolve.

In conclusion, the authors appropriately consider policy. I refer back to the IOM volume, for the main purpose of that report was to shape policy. The response? Despite these tough economic times and the divisions in Washington, people are listening. So policy makers must speak up. The material in this volume will be welcomed by those who both set and advocate for policy. The time is right, the material is current, and the need is great. Congratulations to the authors and editors for their excellent work.

Dan G. Blazer MD, MPH, PhDJP Gibbons Professor of Psychiatry and Behavioral SciencesDuke University Medical CenterDurham, NC, USA

INTRODUCTION

Ilana B. Crome, Li-Tzy Wu, Rahul (Tony) Rao and Peter Crome

There are indications that the number of older people who use substances is increasing, and is likely to continue to do so over the next two decades [1, 2]. Projections suggest that the number of older illicit substance misusers will double from 2006 to 2020 [3]. Inappropriate prescribing, drug interactions and the use of over-the-counter medicines as well as those purchased on the Internet are further cause for concern, as they are likely to result in premature mortality and morbidity, as well as damage to social functioning. Experience in clinical practice (e.g. addiction, old age psychiatry, geriatric medicine, emergency medicine and trauma) suggests that this vulnerable group is a growing but neglected. Further investigation of this cohort is gaining momentum in research activities related to epidemiological trends, clinical treatment outcomes and professional education, and in health and social policy (e.g. models of service delivery). In 2011, the United Kingdom the Royal College of Psychiatrists produced a comprehensive report on older substance misusers, ‘Our Invisible Addicts' – it generated enormous interest and reaction [4].

In this book we explore substance use and misuse (including smoking, drinking, illicit drug use, nonmedical prescription drug use, and dependence) in older people. We have covered thorny issues such as differences in the description and diagnosis of substance use, misuse and dependence in older people as compared with younger ages. By examination of recent trends, projections and predictors, we have charted the risk and resilience features, such as inequalities, culture and ethnicity, drawn from the longitudinal studies of ageing. We take the life course approach, which advances the understanding of older substance users from the social, biological, psychological and medical perspectives. We examine the effects and adverse acute and chronic impact of substances on the physical, psychological, psychiatric and social function. We have outlined what the core features of comprehensive geriatric assessment should encompass. We have paid special attention to the clinical consequences and complications – physical and psychiatric – including falls, trauma, pain, cancer, cardiovascular, respiratory, neuropsychiatric, dementia, confusion, depression, anxiety and paranoid disorders. This is because of the poorer outcomes associated and the greater likelihood that older people with substance problems might suffer from combined disorder.

Treatment interventions and outcomes in older people, in concert with the development of service delivery models, are a major focus. The spotlight has been on treatment options – being sensitive to the special needs of older people (sensory, mobility, cognitive); cultural context of treatment; the range of options (i.e. one-to-one, group, family); pharmacological (alcohol, opiate, nicotine and co-morbid disorders); psychological/psychosocial approaches (e.g. general counselling), specific techniques (e.g. motivational enhancement and cognitive behavioural therapy); self-help/mutual aid, the role of social networks and creative programmes. Social factors in recovery and rehabilitation (including statutory services such as home care) and the impact of housing (e.g. sheltered accommodation) have been emphasized. Where available we have presented information on service models and service designs. Paramount is the identification of gaps that can stimulate future research. Recommendations for policy directives, in relation to current and future practice, build on the synthesis of knowledge acquired during the evolution of the book.

We have pointed to the diverse treatment settings at which older substance misusers might present or need emergency or continuing care. These include intensive care, trauma, pain management, cardiovascular and respiratory units, gastroenterology, oncology, neurology, ophthalmology, primary care, geriatric medicine, old age psychiatry wards, nursing homes, renal and urological units, and even prison. We have embraced ethics and philosophies of care of older people, such as the role of users, carers and communities.

We hope that the book will be of interest to old age psychiatrists, addiction psychiatrists, geriatricians, gerontologists, educators, epidemiologists, psychologists, clinical social workers, case managers, sociologists, policy makers, researchers, general health-care providers, commissioners, and politicians. Undergraduate and postgraduate students across the range of clinical, research and policy arenas as well as related specialist areas such as epidemiology, clinical medicine, psychology, economics, sociology, social and health policy should also find it engaging and stimulating.

Our aim has been to review, reflect upon and draw together the most up-to-date information available on a fast growing topic. We hope this will be a resource for practitioners (be it in geriatric medicine, old age psychiatry as well as other professional groups), policy makers and educators who are involved in the prevention of ill health of older people and who provide interventions. That the public, as well as professionals, become increasingly concerned is a key aspiration.

We have been so privileged to work with distinguished colleagues around the world who have enriched the process and have come together to produce something that we believe does take the field forward. We would like to acknowledge their passion, goodwill, enthusiasm, patience, humour and rigour.

References

1. Wu, L.T. and Blazer, D.G. (2011) Illicit and nonmedical drug use among older adults: A review.

Journal of Aging and Health

,

23

, 481–504.

2. Wu, L.T. and Blazer, D.G. (2014) Substance use disorders and psychiatric comorbidity in mid and later life: a review.

International Journal of Epidemiology

,

43

(2), 304–317.

3. Han, B., Gfroerer, J.C., Colliver, J.D. and Penne, M.A. (2009) Substance use disorder among older adults in the United States in 2020.

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, 88–96.

4. Crome, I.B., Rao, T., Tarbuck, A.

et al

. (2011) Our Invisible Addicts. Royal College of Psychiatrists Council Report 165. Royal College of Psychiatrists, London.

LIST OF ABBREVIATIONS

AA

Alcoholics Anonymous

AADL

Advanced Activities of Daily Living

ACE-R

Addenbrooke's Cognitive Assessment – Revised

ADE

Adverse Drug Event

ADL

Activities of Daily Living

ADR

Adverse Drug Reaction

AIDS

Acquired Immune Deficiency Syndrome

ALN

Alcohol Liaison Nurse

ARPS

Alcohol-Related Problem Survey

ASAM

American Society of Addiction Medicine

AUD

Alcohol Use Disorder

AUDIT

Alcohol Use Disorders Identification Test

AUDIT C

Alcohol Use Disorders Identification Test Consumption

BAC

Blood Alcohol Concentration

BAL

Blood Alcohol Level

BI

Brief Intervention

BRFSS

Behavioural Risk Factor Surveillance System

BRITE

Brief Intervention and Treatment for Elders

CAGE

Cut down, Annoyed by criticism, Guilty about drinking, Eye-opener drinks

CARET

Co-morbidity Alcohol Risk Evaluation Tool

CBC

Complete Blood Count

CBT

Cognitive Behavioural Therapy

CDC

Centers for Disease Control and Prevention

CDT

Carbohydrate Deficient Transferase

CGA

Comprehensive Geriatric Assessment

CI

Confidence Interval

CIDI

Composite International Diagnostic Interview

CMHT

Community Mental Health Team

CNS

Central Nervous System

COPD

Chronic Obstructive Pulmonary Disease

CSAT

Center For Substance Abuse Treatment

CT

Computed Tomography

DA

Dopamine

DAST

Drug Abuse Screening Test

DAWN

Drug Abuse Warning Network

DHHS

Department of Health And Human Services

DSM

Diagnostic and Statistical Manual of Mental Disorders

DSM-IV

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

DSM-5

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

E-CBT

Extended Cognitive Behavioural Therapy

ECHR

European Convention of Human Rights

e-combined

Extended combined treatment

ED

Emergency Department

EEG

Electroencephalogram

EMCDDA

European Monitoring Centre for Drugs and Drug Addiction

E-NRT

Extended Nicotine Replacement Therapy

ENSPM

English National Survey of Psychiatric Morbidity

EtG

Ethyl Glucuronide

EtS

Ethyl Sulfate

FDA

Food and Drug Administration

FRAMES

Feedback, Responsibility, Advice, Menu of options, Empathy, Self-efficacy

GABA

Gamma-Aminobutyric acid

GATS

Global Adult Tobacco Survey

GFR

Glomerular Filtration Rate

GGT

Gamma-Glutamyl Transferase

GP

General Practitioner

HCV

Hepatitis C Virus

HIPAA

Health Insurance Portability Rehabilitation Act

HIV

Human Immunodeficiency Virus

IADL

Instrumental Activities of Daily Living

ICD-10

International Classification of Diseases, Tenth Revision

IDUs

Injection Drug Users

IP

Inappropriate Prescribing

IT

Information Technology

LCA

Latent Class Analysis

LSD

Lysergic Acid Diethylamide

LTCs

Long-Term Conditions

MAOI

Monoamine Oxidase Inhibitor

MAST

Michigan Alcoholism Screening Test

MAST-G

Michigan Alcoholism Screening Test – Geriatric version

MATCH

Matching Alcoholism Treatments to Client Heterogeneity

MCA

Mental Capacity Act

MCV

Mean Corpuscular Volume

MET

Motivational Enhancement Therapy

MH/SU

Mental Health/Substance Use

MI

Motivational Interviewing

MM

Moderation Management

MMAST-G

Mini-Michigan Alcoholism Screening Test – Geriatric

MMSE

Mini-Mental State Examination

mPFC

Medial Prefrontal Cortex

MRI

Magnetic Resonance Imaging

NCHS

National Center for Health Statistics

NCPIE

National Council on Patient Information and Education

NDTMS

National Drug Treatment Monitoring System

NESARC

National Epidemiologic Survey on Alcohol and Related Conditions

NGO

Non-Governmental Organization

NHIS

National Health Interview Survey

NHS

National Health Service

NHSDA

National Household Survey on Drug Abuse

NIAAA

National Institute on Alcohol Abuse and Alcoholism

NICE

National Institute for Health and Clinical Excellence

NIDA

National Institute of Drug Abuse

NLAES

National Longitudinal Epidemiologic Survey

NMDA

N-methyl-D-aspartate

NRT

Nicotine Replacement Therapy

NSAID

Non-Steroid Anti-Inflammatory Drug

NSAL

National Survey of American Life

NSDUH

National Survey on Drug Use and Health

OR

Odds Ratio

OTC

Over-The-Counter

PCMH

Patient-Centered Medical Home

PET

Phosphatidyl Ethanol

PIM

Potentially Inappropriate Medication

PPO

Potential Prescribing Omission

PTSD

Post-Traumatic Stress Disorder

QF

Quantity/Frequency

RPT

Relapse Prevention Therapy

SAMHSA

Substance Abuse and Mental Health Services Administration

SBIRT

Screening of substance misuse, Brief Intervention, and Referral to Treatment

SDDCARE

Senior Drug Dependents and Care Structure Project

shARPS

Short Alcohol-Related Problem Survey

SLCHS

Southeast London Community Health Survey

SMAST

Short Michigan Alcoholism Screening Test

SMAST-G

Short Michigan Alcoholism Screening Test – Geriatric Version

SMCD

Substance Misuse and Co-morbid Mental Disorders

STOPP

Screening Tool of Older Persons' Prescriptions

SUD

Substance Use Disorder

TEDS

Treatment Episode Data Set

THC

Δ9-tetrahydrocannabinol

TIP

Treatment Improvement Protocol

TSF

Twelve-Step Facilitation

UC

Usual Care

VTA

Ventral Tegmental Area

WHO

World Health Organization

Section 1LEGAL AND ETHICAL ASPECTS OF CARE FOR OLDER PEOPLE WITH SUBSTANCE MISUSE

Chapter 1NEGOTIATING CAPACITY AND CONSENT IN SUBSTANCE MISUSE

Kritika Samsi

Social Care Workforce Research Unit, King's College London, UK

Introduction

Mental capacity is an individual's ability to make autonomous decisions for themselves, the significance of which has increased with greater recognition of the involvement of the individual as a ‘self-governing welfare subject' [1] with greater emphasis on personal choice and self-determination of his or her own health and social care decisions [2].

The complexity of problems associated with substance use in older people means that there are particular risks around capacity or ‘competency', through impairment in cognition, judgement and function [3]. There could be co-morbid mental health problems that may further contribute to their impairment [4]. Decision making capacity is vital not only for individuals to be able to express their preferences for long-term care but also in the case of immediate in-patient care, when practitioners may face complex decision making issues. Some of these issues include: (i) timing of capacity assessment; (ii) conflict between presence of capacity, alongside evidence of self-neglect and need for medical care; and (iii) the role of the practitioner in encouraging the older person to give up addictions that are harmful to them [3].

Substance abuse and capacity

There had been diagnostic limitations in the Diagnostic and Statistical Manual of Mental Disorders iv (DSM-iv) in how substance abuse and dependence were classified, resulting in what some believed were deceptively low rates of identification of older individuals with substance abuse and dependencies [5]. Some of the criteria used – such as giving up activities and the inability to fulfil major role obligation at work – were also criticized for being irrelevant to an older population [5].

The physiological impact of acute alcohol intoxication is more severe in the elderly, with an increase in the risk of delirium [5]. In the brain, alongside an acute confusional state, cerebral atrophy can result in global cognitive impairment [5]. Mental capacity, judgment and ability to consent can also be affected. Most types of dementia are more prevalent in older people with alcoholism [6].

Impaired decision making capacity characterizes substance misuse. The diagnostic criteria according to the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) acknowledge this, as substance dependence is described as persistent use despite knowing the negative physical and psychological effects of the substance [7]. The self-destructive choices and decisions made by substance abusers have been termed ‘myopia', which are deficits in emotional signalling that produce poor short-term decisions for immediate gains despite potential for higher losses in the future [8].

Mental capacity legislation

Several western countries have existing legislation that addresses and protects autonomy, capacity, dignity and decision making for vulnerable people. None of this legislation codifies ‘age' as a specific vulnerability in itself, and safeguarding incapacity or deteriorating capacity more wholistically is prioritized instead. By handing over decision making powers to a trusted relative or nominated consultee, an individual can choose who makes decisions on their behalf and, thereby, assert their choices and preferences through them.

The Guardianship and Administration Act was introduced in 1993 in South Australia and in 2000 in Queensland, two of Australia's largest states. The Substitute Decisions Act and the Health Care Consent Act were introduced in Ontario, Canada, in 1992 and 1996, respectively. Most of these Acts incorporate the same principles, with variations in the way capacity assessments are carried out, and how care priorities are determined. Presuming an individual has capacity, unless proven otherwise, is the guiding principle in all of these Acts.

Scotland, England and Wales introduced legislation around capacity more recently. Scotland introduced the Adults with Incapacity Act in 2000, and the Mental Capacity Act 2005 was introduced in 2007 in England and Wales; both are applicable to those over the age of 16 years.

Using the Mental Capacity Act 2005 as a case example in England and Wales, the rest of this chapter illustrates some of the principles embedded in current legislation in the area of capacity and consent, focusing specifically on its applicability to those with a history of substance abuse.

Mental Capacity Act 2005

The Mental Capacity Act 2005 (MCA), implemented in England and Wales in 2007, introduced a variety of provisions to safeguard and enhance the rights of vulnerable people with compromised capacity [9]. Prior to the Act, it was sometimes challenging to ascertain ‘mental capacity' to make decisions and different approaches were described under mental capacity legislation and mental health legislation [1].

A central principle of the MCA is the presumption that all adults have the capacity to make decisions for themselves, unless proven otherwise. Provisions for surrogate decision making should only be resorted to after it has been proved that an individual lacks capacity. The other four central principles of the Act include:

A person must be given all practicable help before anyone treats them as not being able to make their own decisions.

A person is not to be treated as unable to make a decision merely because he makes an unwise decision.

Anything done or any decision made under this Act for or on behalf of a person who lacks capacity must be done, or made, in his/her best interests.

Anything done or decided for or on behalf of a person who lacks capacity should be the least restrictive of their basic rights and freedoms.

Capacity assessment

There are a number of capacity and decision making assessment tools currently available [4]. In the MCA, a four-stage assessment of decision making ability is required to prove that an individual is unable to make a specific decision at that specific time. These include asking the following four questions:

Does the person have a general understanding of what decision they need to make and why they need to make it?

Does the person have a general understanding of the likely consequences of making, or not making, this decision?

Is the person able to understand, retain, use and weigh up the information relevant to this decision?

Can the person communicate their decision (by talking, using sign language or any other means)? Would the services of a professional (such as a speech and language therapist) be helpful?

Inherent to this assessment is the recognition that capacity is not an absolute state but varies over time and with the decision that is required to be made. For substance misusers, this becomes an even more crucial issue, as their states of incapacity may fluctuate according to the level of intoxication or delirium. Capacity should, therefore, be seen as decision specific, rather than all encompassing. If a person is deemed to be ‘lacking capacity', it means that they lack capacity to make a particular decision or take a particular action for themselves at the time the decision or action needs to be taken. The MCA applies to anyone who has ‘an impairment of or disturbance in the functioning of the mind or brain' and was warmly welcomed for not using the phrase ‘mental disorder', which may not be appropriate to a person with substance abuse problems. Similarly, an ‘incapable' adult is defined in the Scottish and the Canadian legislation as someone unable to act, make, communicate, understand or retain the memory of decisions.

Legal frameworks such as the MCA 2005, codifying complex phenomena that can threaten the autonomy of vulnerable individuals, have wide applicability: from types of decisions, such as day-to-day support [10], advance decision making about personal health and welfare [11], end of life care [12]; to different settings [13], such as medical encounters [14] and long-term care facilities [15]; and to a wide range of professionals [16–19].

Capacity and unwise decisions

A central feature of the Mental Capacity Act is the acknowledgement that individuals who have the capacity to make their own decisions are in a position to make what may be deemed ‘unwise' decisions. In many cases, this applies to risk taking, such as gambling, forming relationships and choosing a certain type of lifestyle. In the case of substance misuse, individuals may choose to continue to use a substance in spite of being aware of its harmful effects. If that individual is deemed as having the capacity to make a decision for themselves – that is if that individual is shown as being able to weigh up the consequences of their decision and still choose to use a particular substance – the MCA safeguards that individual's decision making capacity by suggesting that decisions otherwise deemed ‘unwise' are legally acceptable.

Consent, barriers to decision making and substituted decision making

If capacity is an individual's ability to make decisions, ‘consent' can be seen as granting permission or agreeing to the decisions themselves. In relation to consenting, the relevance of the MCA covers three relevant areas: substituted decision making powers, best interest principles and independent decision makers.

The MCA facilitates substituted decision making through the uptake of Advance Care Planning (ACP) in three forms:

Statements of wishes and preferences for future care that an individual would want, that was made before they lost capacity. These can include requests for specific medical treatments, such as artificial nutrition and hydration. Although these written statements are not binding, a practitioner must consider them before making a proxy decision on an individual's behalf, and any reason they are choosing to go against the written statement of wishes should be clearly recorded.

Advance decisions to refuse certain treatment where an individual stipulates that they do not want a particular intervention, such as artificial nutrition or hydration, or withdrawal of life support system. These are more binding on practitioners. (

Box 1.1

shows provisions outlined in the MCA).

Granting a trusted friend or relative Lasting Power of Attorney (LPA) to cover health and welfare decisions. Granting LPA is a powerful principle since the MCA was introduced, as it enables individuals to have their wishes and preferences included at a time when they may be unable to contribute themselves.

Box 1.1 Provisions for Advance decisions outlined in the MCA

24.1 ‘Advance decision' means a decision made by a person (‘P'), after he has reached 18 and when he has capacity to do so, that if:

at a later time and in such circumstances as he may specify, a specified treatment is proposed to be carried out or continued by a person providing health care for him, and

at that time he lacks capacity to consent to the carrying out or continuation of the treatment, the specified treatment is not to be carried out or continued.

A health and welfare LPA can run in conjunction with a financial LPA, which sets out a decision maker for property and financial affairs. Surrogate decision makers may also be granted the power to make decisions about life-sustaining treatment. (Provisions relating to an LPA outlined in the MCA are outlined in Box 1.2.)

Box 1.2 Provisions for Lasting Power of Attorney outlined in the MCA

9.1 A lasting power of attorney is a power of attorney under which the donor (‘P') confers on the donee (or donees) authority to make decisions about all or any of the following:

P's personal welfare or specified matters concerning P's personal welfare, and

P's property and affairs or specified matters concerning P's property and affairs, and which includes authority to make such decisions in circumstances where P no longer has capacity.

There are some pre-conditions that govern the behaviour of an LPA, such as any substitute decision must be made in the individual's best interest [20]. Moreover, there are a number of decisions that are outside the remit of substitute decision making, where it is deemed impossible to be able to gauge another's likelihood of consent (section 27 of the MCA). For instance, nothing in the Act permits a substituted decision to be made regarding any of the following:

consenting to marriage or a civil partnership;

consenting to have sexual relations;

consenting to a decree of divorce on the basis of two years' separation;

consenting to the dissolution of a civil partnership;

consenting to a child being placed for adoption or the making of an adoption order;

discharging parental responsibility for a child in matters not relating to the child's property; or

giving consent under the Human Fertilisation and Embryology Act 1990.

Best interest decisions

An individual's best interest is always protected under capacity legislation. The MCA 2005 deems that all surrogate decisions should be in an individual's best interest. However, research has indicated prevalent discrepancies about how this may be rolled out in practice [21], especially in relation to challenges with resolving conflicts [22]. Best interest decision making includes a checklist, which takes into account key indicators of an individual's well-being. In complex cases, such as working with older people with substance misuse problems, assessing impaired capacity may not be straightforward and there may be additional criteria to take into account. Hazelton et al. [3] suggest delaying significant decisions for as long as possible, or at least until acute effects have passed, as well as differentiating between alcohol-related cognitive deficits and addiction-related denial. Using the least restrictive option is also always recommended. (Box 1.3 shows a best interest checklist outlined in the MCA.)

Box 1.3 Best interest checklist in the MCA

Can the decision be delayed to when the individual may have capacity?

No decision should be based on the person's appearance, age, medical condition, or behaviour.

All relevant information should be considered, and every attempt to involve the person in the decision should be made.

Any written or verbal statement expressing the individual's wishes, values, choices, preferences, beliefs and feelings should be considered.

Views of family members, partners or other supporters who may know the person better should be incorporated.

If the decision is about treatment, the decision maker should not be motivated by a desire to bring about their death, nor by assumptions of their quality of life.

Independent decision makers

Family networks of older people with a history of substance misuse may be absent, chaotic and challenging to engage. A relationship between the older person and their family relative may not be based on trust or prior knowledge of preferences of the individual.

Legislation has provided for these cases through the establishment of new roles; for example, in England and Wales, that of an Independent Mental Capacity Advocate (IMCA), or someone who can step in to the role of substitute decision maker, to make major decisions regarding treatment or accommodation for a person with impaired capacity [23]. Definition of roles and remits in all of the legislation largely overlap, with their main remit being to consider the best interests of the vulnerable person in order to make the decision that contributes most to their well-being (Box 1.4).

Box 1.4 Stipulations covering an Independent Mental Capacity Advocate

36.2 The regulations may, in particular, make provision requiring an advocate to take such steps as may be prescribed for the purpose of:

providing support to the person whom he has been instructed to represent (‘P') so that P may participate as fully as possible in any relevant decision;

obtaining and evaluating relevant information;

ascertaining what P's wishes and feelings would be likely to be, and the beliefs and values that would be likely to influence P, if he had capacity;

ascertaining what alternative courses of action are available in relation to P;

obtaining a further medical opinion where treatment is proposed and the advocate thinks that one should be obtained.

Conclusion