An Introduction to Dual Diagnosis and Older Adults
The term “dual diagnosis” (sometimes referred to as concurrent disorder) refers to when a person has both a substance use problem and a mental health problem. How common are these among older adults? Here is a brief summary:
Dual Diagnosis and Older Adults
There are different rates of dual diagnosis among older adults, depending on whether you are talking about depression, bi-polar disorder, or organic disorders.
A. Bi–Polar Disorder (Manic- depression): According to Cassidy, Ahearn & Carroll (2001), the rates of lifetime substance abuse are high among or people of all ages who have bipolar disorder. Among 392 patients hospitalized with bi-polar disorder, 48.5 percent also had alcohol abuse problems and 43.9% had problems with drug abuse. Men had higher rates of alcohol or drug abuse than women. The researchers noted that the rates decrease in older age groups, substance abuse is still present at clinically important rates in older adults. The people with concurrent / dual diagnosis disorder had more psychiatric hospitalizations
B. Depression & Other Disorders: Devanand (2002) finds that alcohol abuse and alcohol dependence commonly are evident along with late-life depression. Older depressed persons are three to four times more likely to have alcohol-related problems than are older adults who are not depressed.
The prevalence of alcohol problems is 15-30 % among persons with major late-life depression. Devanand notes this combination of problems can worsen the outlook for effective treatment, but some evidence suggests that the best possible outcome occurs when successful treatment of depression is combined with reduction of alcohol use.
Devanand states: “The prevalence of personality disorders with late-life depression is about 10-30 percent, especially among patients with early onset of depressive illness.” The prevalence of panic disorder and obsessive-compulsive disorder with depression is comparatively low, but generalized anxiety disorder is not uncommon. Studies have not fully resolved the question of whether a comorbid anxiety disorder affects the treatment and prognosis of late-life major depression.
C. Depression Across the Life Span: Reifman & Welte (2001) compared five groups of people:
-- lifetime abstainers from alcohol;
-- individuals who drank, but never experienced any alcohol-related problems or symptoms;
-- drinkers who experienced alcohol-related problems only before age 60;
-- those who experienced alcohol-related problems only after age 60; and
-- those who experienced alcohol-related problems both before and after age 60.
Drinkers who never experienced alcohol problems had the lowest depressive symptoms and that individuals who experienced alcohol problems both before and after age 60 had the highest. Earlier alcohol problems (around ages 20 and 40) predicted having depression in later life.
D. Alcohol Abuse Rates are High among Older Patients in Psychiatric Hospitals: Blixen & McDougall (1997) examined the records of 101 community-dwelling older adults, aged 65 years and over, who were discharged from private psychiatric hospitals back into the community to their homes. They found that over one-third (37.6 percent) of the sample had a substance abuse problem in addition to a psychiatric disorder. They note this is quite a bit higher than prevalence rate of 19 percent found among older psychiatric patients in the public hospitals.
They also found HIGHER RATES of alcohol and other substance abuse among the older patients compared to younger (71% of the older patients had alcohol disorders, and another 26 % had problems with both alcohol and other drugs). In the younger group, the rate was “only” 34% for alcohol problems and 16% for both alcohol and other substances.
E: Young and Old Have Different Problems: Solomon & Stark, ( 1993) found alcohol was the most commonly used drug for both groups and there were poly-drug users in both groups. Significant social and psychiatric pathology were also common in both groups. Older persons were more likely to abuse benzodiazepines, be married, have difficulties with personal hygiene and activities of daily living, and neurologic and cognitive signs and symptoms, and to have psychotic symptoms, threaten violence, lie about their drug use, and to be non-compliant with medical care. Younger persons were more likely to experience multiple job changes, housing, and legal problems, black outs, use "street" drugs, and to have their addiction as their chief complaint.
F. “Problem behaviours”: McAleer, A. & Wrigley, M. (1998) looked at found 13 sex offending older patients (indecent assault, masturbation in public and lewd remarks) referred to psychiatry services. They found one half of them had concurrent alcohol problems. The people also had diagnoses of vascular dementia, frontal lobe dysfunction, Alzheimer's disease, chronic schizophrenia, or depression along with alcohol abuse. Most had a psychiatric diagnosis with organic brain damage.
Blixen, C.E.; McDougall, G.J.; Suen, L.J. (1997) Dual diagnosis in elders discharged from a psychiatric hospital. International Journal of Geriatric Psychiatry, 12(3),307-313.
Cassidy, F., Ahearn, E.P. & Carroll, B.J. (2001) Substance abuse in bipolar disorder. Bipolar Disorders, 3(4),181-188, 2001
Devanand, D.P. (2002) Comorbid psychiatric disorders in late life depression. Biological Psychiatry, 51(3),236-242.
McAleer, A.& Wrigley, M. (1998) Study of sex offending in elderly people referred to a specialized psychiatry of old age service. Irish Journal of Psychological Medicine, 15(4),135-138.
Reifman & Welte ( 2001) Depressive symptoms in the elderly: Differences by adult drinking history. Journal of Applied Gerontology, 20(3),322-337.
Solomon, K.& Stark, S. (1993) Comparison of older and younger alcoholics and prescription drug abusers: History and clinical presentation. Clinical Gerontologist, 12(3),41-56.
Page last updated: Sunday October 31, 2004
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