The Royal College of Psychiatrists has released a report on substance misuse in older adults. The college report CR 165 is located here and there is an interview with one of the authors of the report Professor Ilana Crome here (reviewed here). The report is detailed and it is difficult to do this justice in a brief summary and so the reader is directed to the link above. However several principles arise from the report. The authors recommend that older adults are screened for substance misuse in primary care using standardised screening tools, that the recommended upper limit for older adults should be reduced (they recommend 11 units a week), that older adults with substance misuse have many unmet needs and benefit from treatment, that binge drinking limits for older adults should be reduced (they recommend 4.5 units as a limit for men and 3 units for women) and that local policies should be developed to facilitate effective management. The authors also have a number of recommendations about training and research including further evaluation of the therapeutic intervention in older adults with substance misuse. There are seven recommendations and components of future strategic direction including an emphasis on multi-agency partnership. There are detailed outlines of therapeutic interventions in the Appendices. What is also interesting is that there are discussion of exemplary service models. One that I found very interesting was the North Southwark team in which it was noted that ‘up to 50% of admission of older people involved a dual diagnosis’ and they go on to note the importance of alcohol misuse in these presentations. In 2002 5% of patients were identified with alcohol misuse and the psychiatrist undertook an MSc in Public Health Medicine. A few years on and with a multidisciplinary community programme to address alcohol misuse the admissions were reduced to 5%.
The report has generated considerable debate in the media (see links below). Indeed spending a little time looking through the comments on two of the sites below, many of the commentators are critical of the report. A number of themes recur in the posts including perceived interference in the lives of older adults, the actions of a perceived ‘nanny state’, anecdotal cases of alcohol consumption in those that reach an advanced age and the association with enjoyment of life. The comments thus provide an ‘audit trail’ for the debate that is happening in society (although there may be a bias in selection in terms of both readerships and those who have commented rather than just read) and this would form a very useful basis for a qualitative analysis. What was striking to me in reading the comments was that the issues that were frequently discussed by the commentators were slightly different to the main emphasis in the report. For instance the report produces important guidance for psychiatrists to help give them the best advice for the patients that they can provide. Such guidance assumes that the patient has a sense of agency – that is that they have a choice on whether to act on the advice rather than being compelled to do so. However many of the comments give an impression of a compulsion and it is curious to see where this is coming from. Another point which arises is the understanding of probability or statistical inference. The report cites a large amount of research undertaken in this area which produces statistical results enabling advice to be given in the form of a balance of probabilities. However in many comments there are references to anecdotal reports of alcohol use in those reaching an advanced age – with the implication of the comment being that in those cases the advice was not valid. This though misses the point about the nature of the findings which provide a balance of probabilities. In other words it is more likely than not. Thus in isolated cases there may be counterexamples but as more outcomes are examined the trend will be towards the results seen in the studies i.e it might work for one person but not for 10. This theme about statistics however is common and it would be interesting to see if in this case it relates to a genuine misunderstanding of statistics or an implied risk/benefit calculation that is not explicitly discussed.
NHS Choices gives the lowdown on the report here.
Silver Surfer article here.
Independent article here.
ITN article here.
Sky News article here.
Telegraph article here.
Metro article here.
Yorkshire Evening Post article here.
Netdoctor article here.
Mail on Sunday article here.
International Business Times article here.
AFP press release here.
Herald Scotland article here.
Irish Independent article here.
NW Evening Mail article here.
Visit Bulgaria article here.
Ghana Business News article here.
Modern Ghana article here.
French Tribune article here.
De Havilland article here.
South Wales Angus article here.
Barchester Healthcare article here.
The Periscope Post article here.
Bournemouth Echo article here.
Best Medical Cover article here.
Leicester Mercury article here.
Bradford Telegraph and Argus article here.
Top News United States article here.
4RFV article here.
Express article here.
Netdoctor article here.
Best Medical Cover article here.
Just Drinks article here.
Candis article here.
On Medica article here.
Mediplacements article here.
The new version of the World Health Organisation Classification of Disease (ICD-11) is displayed in draft version here. This is a work in progress with daily updates and it will allow people to comment from July 2011 onwards. I checked out the Mental and Behavioural Disorders section and there was just a little information there (relating to indexes for mortality) at the moment.
At the Alzheimer’s Forum there is a detailed discussion of a new meta-analysis on the relationship between hypertension and Alzheimer’s Disease. The study actually shows that hypertension is associated with a slight lowering in blood pressure which is the opposite of what you might expect if hypertension contributed to Alzheimer’s Disease. There are certainly studies which support a relationship between cerebrovascular disease and Alzheimer’s Disease and since hypertension raises the risk of cerebrovascular disease the results of this study do seem a little surprising to me. However the authors of the article note that there is a higher risk of Alzheimer’s Disease in people with hypertension in middle age and there is also the possibility that Alzheimer’s Disease itself may predispose to changes in blood pressure which might confound the results. They conclude that more research is needed in this area and in particular researchers need to focus on tightening up the inclusion criterion for their studies.
There has been a recent study looking at response to social stress. The study was modestly sized (32 participants) and the researchers used fMRI to analyse brain activity in response to social stressors. They found that people in urban areas responded differently to those in rural areas. Participants in urban areas were more likely to activate the Amygdala and those in rural areas were more likely to activate the Cingulate Cortex in response to the social stressors presented in the study paradigm. The results are discussed in the context of other researhc which shows a higher prevalence of Schizophrenia in urban areas and the suggestion from this study at least is that growing up in an urban area may lead to a difference in the way the brain responds to stressful situations. However it must be said that this a small study and this hypothesis needs rigorous testing.
The BMJ has an article coauthored by Professor Barnes on whether antidepressants improve negative symptoms in Schizophrenia. The authors conclude that the evidence is equivocal and they offer some practical tips on how to deal with the conclusions from the literature.
A large study (n=13000) confirmed that anticholinergic drugs are associated with cognitive impairment. This relationship was already well established but this was a large longitudinal study (n=13003). The researchers used the Anticholinergic Cognitive Burden Scale (ACBS) to investigate the relationship. For medications with a definite anticholinergic relationship there was a small deterioration in the MMSE over the 2 year follow up (by slightly less than a point) compared to the control group. The study is well covered in an article at NHS Choices.
There are articles on PTSD and the Japanese Tsunami here and here. The articles look at the provision of psychotherapists for PTSD and the anticipation that were will be a large increase in demand as a result of the tragic events that occurred recently.
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