Before we understand the problem we need to understand the historical context for substance use in older Australians because all alcohol and drug use is influenced by he social context in which it occurs .
Homelessness major concern: The Road Home – multiple strategies to reduce homelessness by 2020On any one night in Australia there are approximately 100,000 homeless people but a heterogeneous group. Broadly categorised as being primary homeless – rough sleepers, secondary homeless – in temporary short term accommodation and tertiary – longer term resident of boarding houses etc. Biggest category are secondary homeless are staying with friends, in supported accommodation But cycle between situations so difficult to track over timeBut we need to engage and follow up these groups because despite having high rates of substance use, mental health problems they do not access mainstream health services despite this strong need
Mostly male, average age 49, 15% Aboriginal, left school at 15, ¾ not in labourmarket
As can be seen here mental health disorders were commonplace, more than half respondent reported lifetime depression and a third anxiety or depression.The high rates of liver disease suggest problematic alcohol use and / or hepatitis of some description
The average age of onset of drinking was 17. and average number of drinks on one occasion was 26. Most had experienced multiple attempts at quitting.The majority has sought some sort of assistance for drinking or its consequences
High level of polydrug use
Four categories of ABI were assessed: traumatic brain injury (TBI) such as penetrating and closed head injuries; hypoxic events such as severe blood loss, stroke or opioid overdose; toxic events such as alcohol related brain injury (ARBI); and infectious processes such as meningitis or encephalitis. Participants were asked if they had ever experienced each type of ABI (prompted by specific events) and the number of separate incidents experienced (i.e. lifetime prevalence). These questions were created specifically for the study in consultation with medical practitioners.
Lucy Burns, UNSW, Drugs, Ageing and Homelessness in Australia
Drugs, ageing and homelessness inAustraliaLucy BurnsNational Drug and Alcohol Research Centre, University of New SouthWales, Sydney, Australia
Structure• Evolution of the “baby-boomer” generation• What this means for drug use and ageing inAustralia• Housing issues• What does this mean for policy and practice?
Alcohol use and problems are not new…."...alcohol has existed longer than all human memory. It hasoutlived generations, nations, epochs and ages. It is a part ofus.For most of us it will continue to be the servant of man (andwoman) but will always be the master of some."Our recent historyMorris Chaftez, Founding director, National Institute on Alcohol Abuse and Alcoholism.OUR RECENT HISTORY
Birth of the baby boomers: 1946-64• End of WW2 in 1945 Australias ex-service men and womenreturned to family life after 6 years of war conflict• Came back with legacy: use of substances during• Methamphetamine/ “uppers” to work, alcohol to wind down• Nine months after return childbirth rates soared – more than 4 million born1946-51: “baby boomer generation”• Increased migration to Australia through negotiated agreements with othergovernments and international organisations e.g a system of free or assistedpassages for United Kingdom residents
1950s and 1960s: Teenagers and young adults• Increased advances in science and technology• Widespread testing and use of new synthetic pharmaceuticalsBig Pharma• LSD testing , wider use of new drugs in psychiatryexperimentation with mind altering substancesPrescription drugs and painkillers readily available• Cultural change: new and different music:• rock and roll 1960s: bands, fashion• Vietnam war: use of cannabis by troops and anti-war protestors
1970s and 80s• Between 1962-1972 population leapt by 3 million• Drug experimentation continued: cannabis, LSD, heroin• Vietnam war: anti-war protestors – rebellion against authority• Labor came to power Gough Whitlam• Free university education,• Withdrawal of Australian troops from Vietnam• Anti-discrimination laws for Aboriginal people• Economic prosperity – good health care• Increased longevity
Now and the future: Baby boomers 60+Outcomes of problematic substance used different in older;• Heighted sensitivity and reduced tolerance - same level of alcohol will have anincreased effect• Physiological changes (smaller body volume/mass) = increased impact• Leads to accelerated ageing: impaired stem cell regeneration and increased ratesof cell death• When 40: biological age of 60• Heightened use of medications that interact with alcohol, such as sedatives andtranquillisers• Poor mental and physical healthWomen’s use converging with men’s: roles changed dramatically: moved into workforce –leisure pursuits that were traditionally male dominated eg. Pubs; work social activities.• Increased alcohol use• Telescoping of outcomes – women become sicker quicker
What are the contemporary drugpatterns in older Australians
Daily alcohol use by age: 20070510152025Male Female14-1920-2930-3940-4950-5960+More daily useLess amount but more effect
Places of alcohol consumption0102030405060708090100Home FriendshouseLicensedpremisesRestaurants Parties14-1920-2930-3940-4950-5960+Increasing consumption at homeIncreasing social isolationMedication interaction/ Increased falls
Oxycodone prescriptions per thousand population, by 10 year agegroup,2002 to 20080501001502002503003504002002/03 2003/04 2004/05 2005/06 2006/07 2007/08numberper1,000population20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80+Most by older groupsIncreasing over timeInteraction with other drugs/ alcohol
Overall number of adults aged 50 or olderwith substance use disorder projected todouble by 2020INCREASED SUBSTANCE USE = POORMENTAL HEALTH =INCREASED LIKELIHOODOF LOSS OF HOUSING
Linking substance use and homelessness inolder Australians
Who are homeless in Australia?100,000 Australians homeless each night, sleeping in differentplacesMost staying with friends/relativesHalf are under 24 and 10,000 are childrenIncreasing number of older people homeless (18% 2006Census Counting the Homeless)105,00016,000 20,00047,00021,600020,00040,00060,00080,000100,000120,000total roughsleepers/improviseddwellings (primary)SAAP accommodation(secondary)staying withfriends/relatives(secondary)boarding houses(secondary/tertiary)Homeless Census 2006
Homelessness among older Australians• Both structural and individual factors(1) Individual : as noted poor physical / mental health;(2) Also structural: Lack of acceptable / appropriate housing• 2 groups : first time homeless at older age and chronic homeless• First time homeless more likely to be women• homeless in response to housing market/ policies; welfare safely net• Long-term homeless more likely to be men• poor physical/mental health – more likely to have mental health problems
Structural factors related to homelessness“There is a great divide in Australia between those older people whohave secure and stable housing and those who live precariously inprivate rental accommodation that is unsafe, expensive andinsecure”.Private: Chronic undersupply and high cost• Not age-appropriate: Unwillingness of many landlords to modify houses inline with support needs, housing poorly suited to needs of older people.Social: Limited amount of age appropriate social housingAged care: Residential care required for some BUT• Mainstream services ill equipped• Premature ageing – 54 to 50 and over• Special care needs around ARB
Substance use and homelessness in older people• Substance use patterns more risky• exposed to elements and violence, poor nutrition, lack of opportunitIesfor hygiene• Alcohol problems and traumatic brain injury highly prevalent• History of homelessness + problematic alcohol use + traumatic braininjury = accelerated cognitive deficits• BUT do not necessarily meet the age criteria for access to services althoughmeet physical criteria• THEREFORE Little or no targeted services available for this group
Brain injury among olderwith substance useproblems
Study aims and methodsAim: To describe the association between alcohol use and cognitiveprocesses in older homeless people and implications for servicesMethod:• 50 Face-to-face client participant interviews• Assess demographics, physical and mental health, social support,cognitive performance, use of services• Series of in-depth interviews with key experts in the areas of agedcare and homelessness to determine “gold standard” in care forhomeless people who are also alcohol dependent.
Methods• Clients were recruited from Haymarket Centre for homeless people in innerSydney.• Eligible if 45 years or older and homeless in past 6 months.• Homelessness defined as:• Primary homelessness: sleeping rough on the street or in a car or othermakeshift dwelling• Secondary homelessness: staying in an accommodation service, hotel ormotel, or staying with family or friends because they had nowhere elseto live• Tertiary homelessness: living in a boarding house/hostel or caravan(insecure tenure)
DemographicsCentre% male 70.4Mean age 49.0% Australian born 74.1% identifying as Indigenous 14.8% 10yrs or less education 74.0Mean age first left school 15.0Mean age first employed 16.0% not in the labour market 74.1% in receipt of government benefit 96.3% ever married 51.8% currently in serious, long-term relationship 7.4% ever had children 66.7
Almost all participants had ever slept rough (94%) and stayed in crisisaccommodation (90%).Cycling though different typesEver homeless (%) Mean age (yrs)Slept rough 94.0 31.2Family/ friends 56.0 24.6Stayed in motel 68.0 32.7Crisis accommodation 90.0 33.8Boarding/ rooming house 74.0 29.1Caravan 36.0 26.4Homelessness history
Cycles of homelessnessThe earliest mean age of onset for the different homelessness states• 25 years of age for staying with family and friends• 26 years for staying in a caravan,• 29 years for boarding/rooming house, and• 31-34 years for sleeping rough, crisis accommodation and staying in a motel.This pattern suggests participants experienced precarious housing situationsbefore first experiencing primary homelessness and accessing supportedaccommodation services.
Alcohol variable %Mean onset of regular drinking 17Mean maximum drinks in one day 26% ever abstinent 71Mean number of quit attempts 19% ever talked to health professional about drinking 68% ever received helpful/effective treatment 50% received treatment in past 12 months 28% ever hospitalised overnight because of alcohol 50Mean onset of first hospitalisation 30% ever attended self-help group 42% attended meeting in past 12 months 14Alcohol use95% lifetime alcohol dependence/ 75% currently alcoholdependent
% Past month substance use4423 2116405101520253035404550
Alcohol Related Brian Injury• Brain organ most sensitive to the toxic effects of chronic alcoholconsumption• International literature: high exposure to brain injuries from falls andassaults and injuries• Wernickes encephalopathy: Direct result of alcohol use: thiamine deficiency• Persistent learning and memory problems.• Forgetful and quickly frustrated and have difficulty with walking andcoordination.• Korsakoffs psychosis: problems “laying down” new information) that is themost striking.• For example, these patients can discuss in detail an event in their lives,but an hour later might not remember ever having the conversation.
Brain injury% who experienced eachtype of ABImean number of incidentsamong those whoexperienced each ABITraumatic brain injury (TBI) 59.2 7.6Hypoxic events 53.1 4.3Alcohol related brain injury(ARBI)65.3 16.9Infectious processes 6.1 0.5• Prevalence of any acquired brain injury (ABI) 88%• Montreal cognitive assessment ; mild cognitive impairment• similar scores to people with Alzheimers Disease• Brief Symptom Inventory scored in 98th percentile for psychological distressSuggests there is a need for neuropsychological assessment in this group.
So, what will we see?• More older Australians who are homeless and alcohol dependent• Poor mental health : mood and anxiety disorders, psychoses and cognitivedisorders e.g dementia, delirium and Wernicke-Korsakoff syndrome.• Poor physical health: osteoporosis; ischemic heart disease, stroke, type 2diabetes, colorectal cancer, infection, poor dental care, , lung cancerbronchitis (smoking), falls, liver cirrhosis, dementia, and adverse eventsarising from medication mismanagement.• End stages of long standing BBVs – HIV, Hep C, Hep B• Increased social exclusion: sever links with family and non-drug using friends,death of partners
What it means for housing• Housing that accommodates any disabilities, does not requireextensive maintenance and located close to amenities and publictransport.• Located in familiar neighbourhoods.• Home based care with integrated services – allows for ageing in place• Successful housing associated with previous stable accommodationhistory, revived contacts with family, taking up activities, regular helpfrom housing support workers• Gold standard services EXIST eg Wintringham
Conclusions• “Irrespective of presence of brain injury or anti-social behaviour theseindividuals are entitled to receive care and support that is both appropriateto their needs and which promotes empowerment and independence”• Housing should meet the needs and requirement of this groupBUT• Lack of affordable housing appropriate to needs of older withsubstance use disorders• Lack of sufficient income to maintain an adequate standard of living
“Individuals who are most marginalised will carrythe burden”Further details: Lucy Burns email@example.comTHANK YOU