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News, guidance and resources related to dual diagnosis in older adults
1. Shared learning database
1.1 Improving care for older people with co-existing mental disorders and alcohol misuse.
This shared learning database was developed to improve the health and social outcomes of older people with alcohol misuse, to improve access to services; develop clinically effective care pathways; promote partnerships with other organisations; build a skilled workforce skilled to address unmet need and promote health education, prevention and early intervention.
The following guidance/standards were used to implement the strategy:
Alcohol-use disorders: prevention (PH24). Identification of a consultant old age psychiatrist to provide strategic direction and governance.
Alcohol-use disorders: diagnosis and management (QS11). Each Community Mental Health Team was trained in screening and brief intervention. Screening is monitored and reviewed regularly.
Coexisting severe mental illness and substance misuse: community health and social care services (NG58). Care coordination is tailored to meet the needs of older people throughout the patient journey.
Prior to 2009, there was no clinical governance around the assessment, treatment and care of older people presenting to older adult mental health services with alcohol misuse.
As the number of older people presenting with alcohol misuse increased, services found themselves unable to offer knowledge and skills even at the level of screening. Between 2009 and 2012, a dual diagnosis strategy was developed.
This involved consultation with the SLAM service users and carers group, one local authority (Southwark) in a joint strategic needs assessment and with local substance misuse service providers. The final dual diagnosis strategy has been implemented, with the potential to adapt to the needs of patients under the care of perinatal services.
The database can be downloaded from www.nice.org.uk/sharedlearning/improving-care-for-older-people-with-co-existing-mental-disorders-and-alcohol-misuse
2. New guidance
2.1 Community mental health framework for adults and older adults
This new framework addresses the problems that older people living with dual diagnosis have in having their care discontinued when they fall between mental health and substance misuse services. This may often be through a lack of skills or competences, with the final outcome being that they can be excluded from drug and alcohol services because of their mental health problems or excluded from mental health services as a consequence of their drug and alcohol problems. The framework is based on the principle of inclusivity. Through developing expertise and building workforce competencies, the framework supports NHS England’s Long Term Plan to create “a new community-based offer”. People with relevant expertise should take the lead in establishing formal links and partnerships with local authority-commissioned drug and alcohol services.
The framework can be downloaded from www.england.nhs.uk/wp-content/uploads/2019/09/community-mental-health-framework-for-adults-and-older-adults.pdf
The editor of this themed issue of Advances in Dual Diagnosis would be interested to hear how this framework is being implemented and how relevant expertise is being incorporated into practice. Please contact Tony Rao firstname.lastname@example.org if you are interested in sharing your experiences.
2.2 Supporting older adults who have an alcohol problem and cognitive impairment: a good practice guide.
It is estimated that men who drink more than 60 units of alcohol per week and women who drink more than 50 units per week for a period of five years are more are likely to experience problems with their cognitive function. Alcohol Related Cognitive Impairment (ARCI) is a term that covers the mental disorders associated with alcohol misuse and is part of the wider clinical picture of Alcohol Related Brain Damage (ARBD). ARCI includes Wernicke’s Encephalopathy and Korsakoff Syndrome (amnesic syndrome), together with alcohol-related dementia,. This guide provides best practice in supporting practitioners in the assessment of people living with (ARCI) and their families. It includes information about assessment, identification and support, with reference and links to further resources.
The resource can be downloaded at www.drinkwiseagewell.org.uk/media/publications/pdfs/supporting-older-adults.pdf. Readers may also find the other resources provided by Drink Wise Age Well of interest in broadening knowledge around recent developments to reduce alcohol related harm in older people.
2.3 Alcohol, smoking and substance involvement screening tool – Lite.
The Alcohol, Smoking and Substance Involvement Screening Tool – Lite (ASSIST-Lite) is a shortened version of the ASSIST screening tool. It has been modified and licenced for use in health and social care settings throughout the UK. One version is specifically adapted for use in mental health settings, the other is for use in all other health and social care settings. The ASSIST-Lite will help to identify alcohol, drug and tobacco smoking-related risk and deliver appropriate evidence-based interventions. The version for use in mental health settings includes items from the Mental Health Services Data Set.
For more information about how to use the ASSIST-Lite screening tool to identify alcohol and drug use and tobacco smoking, go to www.gov.uk/government/publications/assist-lite-screening-tool-how-to-use/how-to-use-the-assist-lite-screening-tool-to-identify-alcohol-and-drug-use-and-tobacco-smoking
3. New multimedia resource
3.1 Alcohol alert podcast – institute of alcohol studies: Alcohol and mental health in older people.
This podcast covers a recent review that examines 20 years of alcohol and dual diagnosis policy in older people, using health and social care databases; including grey literature.
Seven major themes in alcohol policy were examined: early policy development, trends in morbidity and mortality, low-risk drinking, prevention of alcohol-related harm, screening and brief intervention, public education and integrated care for dual diagnosis.
The review found that although there has been progress in areas such as screening and brief intervention, evidence of improvements from recent policy implementations reducing alcohol-related harm have yet to be seen. Together with other research on public mental health, this review could be used to implement best policy practice for health and social outcomes in the older population.
The podcast can be downloaded from https://instalcstud.substack.com/p/alcohol-alert-august-2020
4.1 Substance use and ageing special interest group.
The British Society of Gerontology Substance Use and Ageing Special Interest Group is an inter-disciplinary, international community of researchers, practitioners and experts by experience in later life substance use. It welcomes people with any level of experience or interest who are interested in addressing key issues in later life substance use, to progress understanding and inform responsive policy and practice.
As a community of academics (from all career stages), practitioners and experts by experience, it works to understand and address substance use-related harm in older populations. We offer physical and virtual spaces for collaborative thinking to progress research and responsive policy and practice in this field. It aims to provide a forum for sharing and critically discussing current research, policy and practice; consider future directions in substance use and ageing research and develop, cross- disciplinary work and partnership.
If you would like to be part of the Substance Use and Ageing SIG, please contact BSGsubstanceuseSIG@britishgerontology.org. To find out more about the group, contact Dr Beth Bareham Beth.Bareham@newcastle.ac.uk
About the author
Rahul (Tony) Rao is based at the Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.