|Year : 2018 | Volume
| Issue : 2 | Page : 139-142
Inpatient treatment outcomes of aged substance-using patients admitted to a tertiary care center
Preethy Kathiresan, Siddharth Sarkar, Yatan Pal Singh Balhara
Department of Psychiatry and National Drug Dependence Treatment Center, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||27-Dec-2018|
Dr. Preethy Kathiresan
Department of Psychiatry, National Drug Dependence Treatment Center, Psychiatry Office, 4th Floor, Teaching Block, All India Institute of Medical Sciences, New Delhi - 110 049
Source of Support: None, Conflict of Interest: None
Background and Aims: Studies on aged substance users are few from the Indian subcontinent, though they are likely to represent a subgroup of patients with distinct clinical needs. This study aimed to present the inpatient treatment outcomes of such aged substance-using patients admitted to a tertiary care treatment facility in India. Methodology: This descriptive, retrospective chart-based study presents data of aged patients (age 50 years and above) admitted between January and December 2014 at the National Drug Dependence Treatment Centre, Ghaziabad. Results: A total of 72 aged patients were admitted during this period out of total 953 admissions (7.6% of the sample). All of them were male. Forty patients (55.6%) had a diagnosis of alcohol dependence and 32 (44.4%) had a diagnosis of opioid dependence. The mean duration of stay was 12.9 (±9.6) days. Of these 72 patients, treatment could be completed for 57 patients (79.2%), while seven patients left against medical advice, four were discharged on disciplinary grounds, three were shifted to another facility (two due to medical reasons), and one absconded. Treatment completion rate was least among aged patients with only opioid dependence (25.65%). Conclusion: Medical issues may be a consideration of premature discharge among aged patients admitted for the treatment of substance use disorders. Furthermore, treatment noncompletion is more among aged patients with opioid use disorder than among alcohol use disorder. Further studies are needed with prospective methodology for the assessment of various factors associated with treatment completion, which can help to address the treatment needs of aged patients with substance use disorders, which in turn can lead to better treatment outcomes for them.
Keywords: Alcohol dependence, elderly, inpatient, opioid dependence, outcomes
|How to cite this article:|
Kathiresan P, Sarkar S, Singh Balhara YP. Inpatient treatment outcomes of aged substance-using patients admitted to a tertiary care center. J Geriatr Ment Health 2018;5:139-42
|How to cite this URL:|
Kathiresan P, Sarkar S, Singh Balhara YP. Inpatient treatment outcomes of aged substance-using patients admitted to a tertiary care center. J Geriatr Ment Health [serial online] 2018 [cited 2019 Sep 18];5:139-42. Available from: http://www.jgmh.org/text.asp?2018/5/2/139/248633
| Introduction|| |
One of the main outcomes measured in the treatment of substance use disorders is treatment retention. It has been found that those who complete treatment have more favorable outcomes, such as reduction in criminal activities, reduction in substance use, and better quality of life.,, However, patients with substance use disorders have been found to have higher rates of noncompletion of inpatient treatment than patients without substance use disorders. Studies have tried to explore several socio demographic and clinical factors as predictors of retention in substance use disorder treatment.,,
However, such studies among older adults are limited. Older adults with substance dependence represent a group with some unique features. Aging itself leads to increased risk for harm, even with small amount of substance use, than the youth. Furthermore, older adults have higher chance of medical comorbidities as well as use of medications which might interact with the drugs.,
Most studies that predict treatment outcomes among elderly are among patients with alcohol use disorder and have reported either similar or better treatment completion among them compared to adults. A recent study found that among the elderly, gender, marital status, employment status, and referral source were predictors of treatment outcome. The varied needs and issues of the older adults can affect the treatment retention in substance use treatment. However, the literature from India on treatment completion among older adults is limited. One clinic-based study at Chandigarh in a tertiary care hospital found the predominant substance of abuse to be alcohol followed by opioids.
However, there is lack of literature exploring the proportion of older adults who complete inpatient treatment among older adults in India. Hence, this study attempts to present the outcomes of inpatient treatment among the aged population. Some of the previous studies on substance use among older adults have taken 50 years as cutoff., Further, even the WHO Study on Global AGEing and adult health has taken 50 years as cutoff for comparison between younger and older age groups.
| Methodology|| |
The current analysis is based on a retrospective chart-based study conducted at a tertiary care deaddiction center in North India. Briefly, data were obtained from the files and nursing and administrative records of all patients admitted to the center from January 1, 2014 to December 31, 2014. The information extracted included age, gender, residence of the patient, hospital identification number, primary substance of abuse, data of admission, and date of discharge. Duration of inpatient stay was computed from the dates of admission to discharge. The types of discharge were classified as regular discharge, discharge against medical advice, absconds, and discharge on disciplinary grounds. Those patients who were discharged against medical advice, discharged on disciplinary grounds, or absconded were considered as treatment noncompleters, while those who went on planned regular discharge were considered as treatment completers. The study had approval from the Institutional Ethics Committee. Statistical analysis was done using SPSS version 21 (IBM Corp, NY, USA). Descriptive statistics were used to calculate the percentage of treatment completion. Survival graph was plotted for the duration of ward stay. Chi-square and Fisher's exact test were used to find any significant difference in treatment completion among between the aged and nonaged population. A P < 0.05 was considered statistically significant.
| Results|| |
Of the 953 admissions with a clear diagnosis during the study period, 72 patients were aged 50 years and above (7.6% of the sample). Of these 72 patients, 18 were aged 60 years and above (i.e., 25% of the aged sample or 1.9% of the entire sample). All the aged patients were male. In the aged population, 42 patients had dependence on opioids (58.3%), 32 patients had dependence on alcohol (44.4%), and 3 patients had dependence on both alcohol and opioids (4.16%). Among the nonaged population (861), 355 patients had dependence on alcohol (41.23%), 542 patients had dependence on opioids (62.95%), and 45 patients had dependence on both opioids and alcohol (5.23%). These proportions did not significantly differ from the nonaged population (alcohol dependence only: P = 0.6; opioid dependence only: P =0.43; both alcohol dependence and opioid dependence: P =0.69).
The mean duration of stay was 12.9 (±9.6) days. The minimum and the maximum duration of the ward stays were 1 and 70 days, respectively, with a median of 12 days. The duration of ward stay is graphically shown in [Figure 1]. The mean duration of stay for aged was 13.19 days (±9.36 days). The mean duration of stay for nonaged patients was 12.99 days (±7.99 days). There was no significant difference between aged and nonaged population based on duration of admission (t = −0.202; P = 0.84).
Of these 72 patients, treatment could be completed for 57 patients (79.2% of the sample), while seven patients left against medical advice, four were discharged on disciplinary grounds, three were shifted to another facility (2 due to medical reasons), and one absconded. The rate of treatment completion did not differ significantly between the aged and nonaged population (79.2% versus 82.0%, χ2 = 0.346, P = 0.556). As compared to nonaged population, a greater proportion of patients in the aged population were discharged on medical grounds/transferred (4.2% versus 0.9%, χ2 = 6.195, Fisher's exact P = 0.044). Both the patients who were discharged on medical grounds and transferred to a higher center had been admitted for alcohol dependence. One patient had vertigo, decreased peripheral sensation, fecal incontinence, and grade 2 hepatomegaly (history of road traffic accidents), and other patient had alcoholic liver disease, portal hypertension, and gastropathy and developed hepatic encephalopathy.
Among these patients aged 50 years or more, all of the three patients with both alcohol and opioid dependence were treatment completers. Among 29 patients with alcohol dependence only, 27 (93.1%) were treatment completers. Treatment completion rate was least among patients with only opioid dependence (39 patients), in which 29 (74.4%) were treatment completers and 10 (25.6%) were noncompleters.
| Discussion|| |
The study found that among aged patients with substance dependence on alcohol, opioids or both, around 80% completed inpatient detoxification treatment. The results of the study extend the previous literature on aged and elderly individuals with substance use disorders. The presence of a heterogeneous population (alcohol dependent or opioid dependent) provides a perspective on immediate treatment outcomes of patients with opioid dependence as well, literature on which has been lacking.
Our study found no difference in treatment completion between the aged and the younger population. Previous long-term studies have found better treatment retention among older adults in outpatient setting., We could not find any studies that commented on retention rates in inpatient treatment for substance abuse among the elderly population, though some literature suggests that higher age was associated with better retention for detoxification treatment in the usual adult population.,, However, previous studies have shown that older age groups, compared to younger age groups, showed similar prognostic factors, response to different treatment orientations, and various outcomes in the form of lower positive expectancies of alcohol use and lower costs of quitting, higher expected benefits of quitting, and abstinence from alcohol use at the time of discharge from residential treatment setting. There is some evidence to suggest that there is no significant difference in the treatment outcomes in terms of typical alcohol use, maximum alcohol use, and alcohol-related problems among aged, middle-aged and younger population in terms of abstinence and follow-ups after 1 and 5 years of residential treatment. A study done by Bosek found that gender, employment status, marital status, and referral source were the predictors of treatment completion in the elderly.
Medical comorbidity has been hypothesized to be a risk factor for treatment failure among the elderly. In this study also, we found that discharge due to medical grounds was more common among older aged individuals than their younger counterparts. Hence, it is necessary to address the same and an integrated approach addressing both medical disorder and substance use disorder might help in better treatment outcome in this age group.
We could not find any Indian study commenting on reasons for treatment completion among the elderly. However, in a clinic-based study in Chandigarh, the authors have followed older substance abusers and found that nearly 50% only were able to remain abstinent at around 10 months of follow-up. The study also reported that most patients and their caregivers informed them about many older substance abusers in their locality who had not sought treatment due to either lack of awareness of and/or resources to avail the services. Hence, there is probably a huge unmet need in this population in the community. Once a patient is comfortable with the treatment and feels improvement, it is likely that he/she would pass on the information to his/her other friends who might be using drugs. This can help decrease the treatment gap among the elderly. Our study found that treatment completion was least among patients with opioid dependence and maximum among comorbid alcohol and opioid dependence. Lesser treatment completion for opioid use disorder in aged could possibly be due to the inability to deal with withdrawals, which is more common in older opioid addicts. Since opioid use disorder is one of the most common substance use disorders for which old-aged people seek treatment at drug treatment clinics in northern parts of India, it is necessary to find out the reasons associated with treatment noncompletion and resolve the same as much as possible.
The limitations of the study include the methodology being based on retrospective chart review. Hence, the reasons of noncompletion of treatment could be explored in less detail. Further, the information was restricted in terms of reasons of seeking treatment, previous treatment-seeking experiences, actual medical comorbidities at admission and/or transfer, and outcomes after discharge. In addition, the results pertain to single center and generalizations to other services should be done cognizant of the population characteristics, substance use profile of the region, and service organization and delivery parameters. Some clinical factors such as age of onset of substance use, comorbid physical diagnosis/psychiatric diagnosis before admission, type of opioid used among patients with opioid dependence, and presence of injection drug use might affect the retention/completion of the treatment but could not be analyzed in the current study as data were not available reliably.
Despite the limitations, the present analysis attempts to document the rates of noncompletion of treatment of elderly substance users. Further study may try to explore the reasons for noncompletion of treatment among the elderly with substance other use disorders and assess whether incremental changes can lead to better outcomes. Future research should focus on treatment completion on the elderly with prospective methodology so that we can find the various reasons for treatment noncompletion with more reliable and systematic data. Future research should take into account various other factors such as severity of dependence and social support of the patient to improve the treatment. Studies may also focus upon the satisfaction experienced by the aged and elderly substance users and how such satisfaction plays a role in determining immediate and long-term outcomes.
| Conclusions|| |
As discharge due to medical grounds was more common among aged, an integrated approach targeting both medical disorder and substance use disorder should be there. Among aged patients, treatment completion rate was found to be less for those with opioid use disorder than among those with alcohol use disorder. Further studies are needed to assess the various factors that influence the treatment completion in aged, which in turn could lead to better treatment outcomes for aged population.
We express our thanks to Dr. Jawahar Singh and Dr. Namita Gautam who helped with data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Vogel M, Dürsteler KM, Walter M, Herdener M, Nordt C. Rethinking retention in treatment of opioid dependence – The eye of the beholder. Int J Drug Policy 2017;39:109-13.
Moos RH, Moos BS. Participation in treatment and alcoholics anonymous: A 16-year follow-up of initially untreated individuals. J Clin Psychol 2006;62:735-50.
Siqueland L, Crits-Christoph P, Gallop R, Barber JP, Griffin ML, Thase ME, et al.
Retention in psychosocial treatment of cocaine dependence: Predictors and impact on outcome. Am J Addict 2002;11:24-40.
Pages KP, Russo JE, Wingerson DK, Ries RK, Roy-Byrne PP, Cowley DS, et al.
Predictors and outcome of discharge against medical advice from the psychiatric units of a general hospital. Psychiatr Serv 1998;49:1187-92.
Armenian SH, Chutuape MA, Stitzer ML. Predictors of discharges against medical advice from a short-term hospital detoxification unit. Drug Alcohol Depend 1999;56:1-8.
Kenne DR, Boros AP, Fischbein RL. Characteristics of opiate users leaving detoxification treatment against medical advice. J Addict Dis 2010;29:383-94.
Martínez-Raga J, Marshall EJ, Keaney F, Ball D, Strang J. Unplanned versus planned discharges from in-patient alcohol detoxification: Retrospective analysis of 470 first-episode admissions. Alcohol Alcohol 2002;37:277-81.
Kuerbis A, Sacco P, Blazer DG, Moore AA. Substance abuse among older adults. Clin Geriatr Med 2014;30:629-54.
Sarkar S, Parmar A, Chatterjee B. Substance use disorders in the elderly: A review. J Geriatr Ment Health 2015;2:74-82. [Full text]
Bosek RR. Predictors of Treatment Outcome of Elderly Substance Abusers in Treatment Facilities. MN, USA: Doctoral Dissertation, Walden University; 2016.
Grover S, Irpati AS, Saluja BS, Basu D, Mattoo SK. Drug dependence in the geriatric age group: A clinic-based study. Ger J Psychiatry 2008;11:10-5.
Nafiu I, Blow F, Bohnert AS. Older adult substance abuse: Prevalence and risk factors for treatment failure. Am J Ger Psychiatry 2014;22:S104.
Nadkarni A, Murthy P, Crome IB, Rao R. Alcohol use and alcohol-use disorders among older adults in India: A literature review. Aging Ment Health 2013;17:979-91.
Sarkar S, Balhara YP, Gautam N, Singh J. A retrospective chart review of treatment completers versus noncompleters among in-patients at a tertiary care drug dependence treatment centre in India. Indian J Psychol Med 2016;38:296-301.
] [Full text]
Oslin DW, Pettinati H, Volpicelli JR. Alcoholism treatment adherence: Older age predicts better adherence and drinking outcomes. Am J Geriatr Psychiatry 2002;10:740-7.
Fitzgerald JL, Mulford HA. Elderly vs. younger problem drinker ‘treatment’ and recovery experiences. Addiction 1992;87:1281-91.
Hakansson A, Hallén E. Predictors of dropout from inpatient opioid detoxification with buprenorphine: A chart review. J Addict 2014;2014:965267.
Backmund M, Meyer K, Eichenlaub D, Schütz CG. Predictors for completing an inpatient detoxification program among intravenous heroin users, methadone substituted and codeine substituted patients. Drug Alcohol Depend 2001;64:173-80.
Lemke S, Moos RH. Prognosis of older patients in mixed-age alcoholism treatment programs. J Subst Abuse Treat 2002;22:33-43.
Lemke S, Moos RH. Treatment and outcomes of older patients with alcohol use disorders in community residential programs. J Stud Alcohol 2003;64:219-26.