Guest editorial

Citation

Bareham, B. and Rao, R.(T). (2022), "Guest editorial", Advances in Dual Diagnosis, Vol. 15 No. 2, pp. 69-72. https://doi.org/10.1108/ADD-05-2022-047

The need for age-tailored, holistic and integrated support for older adults with dual diagnosis

In our second Older Adults’ Themed Issue of Advances in Dual Diagnosis, we present the year’s progression in our understanding of co-occurring substance use and mental health problems/cognitive impairment in older people and how these can be best addressed in practice. Since our first annual themed issue last year, we have seen the topic of dual diagnosis in older people come ever more to the forefront. Evidence emerging in light of the ongoing coronavirus pandemic has highlighted additional stresses experienced by the older population, including health anxieties as a “vulnerable” group, loneliness and bereavement. With this, we have seen an increase in the prevalence of co-occurring substance use, particularly harmful alcohol use, and mental health problems in older adults (Rao, 2022a; Bareham et al., 2021; Capasso et al., 2021; Eastman et al., 2021; Alpers et al., 2021; Glowacz and Schmits, 2020; Centre for Ageing Better, 2020). We are already seeing and can expect to continue to see, growth in the numbers of older patients requiring support for a dual diagnosis (Rao, 2022a).

Older populations were already hit by the highest rates of alcohol-related harm of all age groups (NHS Digital, 2020); with rates higher still amongst those with co-occurring mental health problems, where alcohol-related death rates are 2.5 times higher than for those without dual diagnosis (Reininghaus et al., 2015). Life transitions experienced in old age, such as retirement and bereavement, put older adults at higher risk of both mental health problems, such as stress, anxiety and low mood, and alcohol issues, where drinking may become an escape (Wadd, 2020). The risk of cognitive impairment also increases substantially with age; and can be both a consequence of and a risk factor for heavy drinking in later life (Wadd, 2020; Yesavage et al., 2002). The older population, therefore, has high and specific needs for support. In this editorial, we echo calls made by the Royal College of Psychiatrists in 2018 (Crome et al., 2018) and highlight the need for age-tailored, holistic and integrated services to support older people with dual diagnosis in the wake of the COVID-19 pandemic.

Older people with co-occurring alcohol and mental health problems fall between services, which are ill-equipped to address their complex and multifaceted needs. These complex needs are increasingly recognised in practice and policy (Crome et al., 2018; Rao, 2022b). However, having alcohol problems commonly leaves this patient group beyond the remit of existing primary care and mental health services. Their referrals are bounced between services, and patients are left unsupported (Crome et al., 2018). Age-appropriate approaches to supporting older people with alcohol use disorders within primary care and community alcohol and mental health services developed to date do not address potential mental health problems and associated support needs (Crome et al., 2018; Kelly et al., 2017). This issue has been highlighted both by practitioners (Crome et al., 2018; Health Do, 2002) and by patient groups. A member of the recovery community involved in shaping research within this field explained:

“The mental health people can’t deal with you, unless you deal with your alcohol, and the alcohol people can’t deal with you because of your mental issues; there should be collaboration to come up with a with a proper plan.”

Patients have highlighted how this represents a barrier to their recovery, as they are left unsupported by services. Whilst such exclusion from services is common across the patient population with co-occurring alcohol and mental health problems, older people with dual diagnosis face additional, age-related barriers. Ill health, hearing and mobility issues, cognitive impairment, and particular sensitivities about problem drinking amongst the older population mean older people have additional needs that must be considered and accommodated by services. These can present challenges to engaging with support – where ill health may affect the attendance of support sessions; hearing difficulties may impact meaningful engagement with any support; many alcohol services are ill-equipped to support older people who have age-related cognitive impairment; mobility issues may make support settings inaccessible and activities that promote mental wellbeing offered through services (Wadd et al., 2017). In recent years, arbitrary upper age limits also excluded older people from some alcohol and mental health support; this has now been addressed in the UK as a consequence of research and lobbying (Wadd et al., 2017). In addition to hearing issues affecting engagement with telephone support, high levels of digital exclusion amongst older people have meant remote support during the COVID-19 pandemic has been unobtainable (Seddon et al., 2020). It will be particularly important to ensure accessible support is available to older people in the wake of the pandemic to ensure older people are not further excluded; as primary care, alcohol and mental health services continue to adopt remote approaches. Age-related factors contributing to co-occurring alcohol and mental health problems in older people must also be addressed with age-tailored support.

Given that two-thirds of older people seeking support from alcohol or mental health services have a dual diagnosis (Bartels et al., 2006), it is crucial that services are prepared to meet the specific needs of this growing patient group through holistic, integrated and age-tailored approaches across primary care and community alcohol and mental health services. Old age psychiatrists, with the skills and understanding required, will play important roles; although primary care, mental health and alcohol support systems as a whole must equip themselves to provide adequate support. With integrated primary care and community mental health services developing within the UK, in accordance with the NHS Long Term Plan and Community Mental Health Framework (Health NEaNIatNCCfM, 2019), there is a significant opportunity to inform developing initiatives across services; ensuring the needs of this patient group are heard and addressed. Learning from the Drink Wise Age Well Programme (2015–2021), which developed age-tailored approaches to support older people with concerns about their drinking, offers insight into some ways in which services might meet the needs of older people with co-occurring alcohol and mental health problems (Wadd, 2020). Involving this patient group in the development of services to ensure their needs are fully understood and met is also essential (Calling Time for Change, 2019). Research and new initiatives within our multi-disciplinary community, which we look forward to sharing in future issues, offer promise to progress practice.

Additional resources

For guidance on approaches to co-designing services with input from the patient population, see: experience-based co-design (Fucile et al., 2017).

For information regarding integrated community mental health services and support for people with dual diagnosis, see: the community mental health framework (Health NEaNIatNCCfM, 2019).

For further information regarding dual diagnosis in older adults, see: Our invisible addicts (Crome et al., 2018).

For insight into age-tailored approaches to supporting older people using alcohol and harmful levels, see: Evaluation of the Drink Wise, Age Well Programme (Wadd, 2021).