Drugs, ageing and homelessness in Australia

Lucy BurnsNational Drug and Alcohol Research Centre, University of New South

Wales, Sydney, Australia

Structure• Evolution of the “baby-boomer” generation

• What this means for drug use and ageing in Australia

• 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 has outlived generations, nations, epochs and ages. It is a part of

us.

For most of us it will continue to be the servant of man (and woman) 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 Australia's ex-service men and women

returned 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 born 1946-51: “baby boomer generation”

• Increased migration to Australia through negotiated agreements with other governments and international organisations e.g a system of free or assisted passages for United Kingdom residents

1950s and 1960s: Teenagers and young adults• Increased advances in science and technology • Widespread testing and use of new synthetic pharmaceuticals

Big Pharma• LSD testing , wider use of new drugs in psychiatry

experimentation 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 an

increased effect • Physiological changes (smaller body volume/mass) = increased impact• Leads to accelerated ageing: impaired stem cell regeneration and increased rates

of cell death• When 40: biological age of 60

• Heightened use of medications that interact with alcohol, such as sedatives and tranquillisers

• Poor mental and physical health

Women’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 drug patterns in older Australians

Daily alcohol use by age: 2007

Male Female0

5

10

15

20

25

14-1920-2930-3940-4950-5960+

More daily useLess amount but more effect

Places of alcohol consumption

Home Friends house

Licensed premises

Restaurants Parties0

20

40

60

80

100

14-1920-2930-3940-4950-5960+

Increasing consumption at homeIncreasing social isolationMedication interaction/ Increased falls

Oxycodone prescriptions per thousand population, by 10 year age group,2002 to 2008

2002/03 2003/04 2004/05 2005/06 2006/07 2007/080

50

100

150

200

250

300

350

400

20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79

80+

nu

mb

er p

er 1

,000

po

pu

lati

on

Most by older groupsIncreasing over time Interaction with other drugs/ alcohol

Overall number of adults aged 50 or older with substance use disorder projected to

double by 2020

INCREASED SUBSTANCE USE = POOR MENTAL HEALTH =INCREASED LIKELIHOOD

OF LOSS OF HOUSING

Linking substance use and homelessness in older Australians

Who are homeless in Australia?100,000 Australians homeless each night, sleeping in different places

Most staying with friends/relativesHalf are under 24 and 10,000 are childrenIncreasing number of older people homeless (18%

2006 Census Counting the Homeless)

0

20,000

40,000

60,000

80,000

100,000

120,000105,000

16,000 20,000

47,000

21,600

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 who have secure and stable housing and those who live precariously in

private rental accommodation that is unsafe, expensive and insecure”.

Private: Chronic undersupply and high cost• Not age-appropriate: Unwillingness of many landlords to modify houses in

line with support needs, housing poorly suited to needs of older people.

Social: Limited amount of age appropriate social housing

Aged 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 opportunitIes

for hygiene

• Alcohol problems and traumatic brain injury highly prevalent

• History of homelessness + problematic alcohol use + traumatic brain injury = accelerated cognitive deficits

• BUT do not necessarily meet the age criteria for access to services although meet physical criteria

• THEREFORE Little or no targeted services available for this group

Brain injury among older with substance use

problems

Study aims and methods

Aim: To describe the association between alcohol use and cognitive processes in older homeless people and implications for services

Method: • 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 aged care and homelessness to determine “gold standard” in care for homeless people who are also alcohol dependent.

Methods• Clients were recruited from Haymarket Centre for homeless people in inner

Sydney.• 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 other

makeshift dwelling• Secondary homelessness: staying in an accommodation service, hotel or

motel, or staying with family or friends because they had nowhere else to live

• Tertiary homelessness: living in a boarding house/hostel or caravan (insecure tenure)

DemographicsCentre

% male 70.4

Mean age 49.0

% Australian born 74.1

% identifying as Indigenous 14.8

% 10yrs or less education 74.0

Mean age first left school 15.0

Mean 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 crisis accommodation (90%).

Cycling though different types

Ever homeless (%) Mean age (yrs)

Slept rough 94.0 31.2

Family/ friends 56.0 24.6

Stayed in motel 68.0 32.7

Crisis accommodation 90.0 33.8

Boarding/ rooming house 74.0 29.1

Caravan 36.0 26.4

Homelessness 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 situations

before first experiencing primary homelessness and accessing supported accommodation services.

Condition % n Age at diagnosis

Treated in last month n

Treated in last month %

Depression 53 56 29(1.6) 15 27

Liver disease 41 43 32(1.5) 14 9

Anxiety 39 41 26(1.6) 11 27

Psychosis 31 32 25(1.5) 9 28

Asthma 28 29 15(3.3) 7 24

Feet problems

23 24 35(3.7) 3 13

Headaches 25 26 29(3.7) 2 8

Epilepsy 13 14 25(2.9) 6 43

Health issues

Uncontrolled chronic conditions; mental health, asthma and epilepsyBSI: 98th percentile for psychological distress

Alcohol variable %

Mean onset of regular drinking 17

Mean maximum drinks in one day 26

% ever abstinent 71

Mean 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 50

Mean onset of first hospitalisation 30

% ever attended self-help group 42

% attended meeting in past 12 months 14

Alcohol use

95% lifetime alcohol dependence/ 75% currently alcohol dependent

% Past month substance use

Cannabis Sedative Amphetamine Opioid Cocaine0

5

10

15

20

25

30

35

40

45

50

44

2321

16

4

Alcohol Related Brian Injury• Brain organ most sensitive to the toxic effects of chronic alcohol

consumption

• International literature: high exposure to brain injuries from falls and assaults 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 and

coordination.

• Korsakoffs psychosis: problems “laying down” new information) that is the most 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 each type of ABI

mean number of incidentsamong those who

experienced each ABI

Traumatic brain injury (TBI) 59.2 7.6

Hypoxic events 53.1 4.3

Alcohol related brain injury (ARBI)

65.3 16.9

Infectious processes 6.1 0.5

• Prevalence of any acquired brain injury (ABI) 88%

• Montreal cognitive assessment ; mild cognitive impairment • similar scores to people with Alzheimer's Disease

• Brief Symptom Inventory scored in 98th percentile for psychological distress Suggests 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 cognitive disorders e.g dementia, delirium and Wernicke-Korsakoff syndrome.

• Poor physical health: osteoporosis; ischemic heart disease, stroke, type 2 diabetes, colorectal cancer, infection, poor dental care, , lung cancer bronchitis (smoking), falls, liver cirrhosis, dementia, and adverse events arising 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 require

extensive maintenance and located close to amenities and public transport.

• Located in familiar neighbourhoods.

• Home based care with integrated services – allows for ageing in place

• Successful housing associated with previous stable accommodation history, revived contacts with family, taking up activities, regular help from housing support workers

• Gold standard services EXIST eg Wintringham

Conclusions• “Irrespective of presence of brain injury or anti-social behaviour these individuals are entitled to receive care and support that is both appropriate

to their needs and which promotes empowerment and independence”

• Housing should meet the needs and requirement of this group

BUT

• Lack of affordable housing appropriate to needs of older with substance use disorders

• Lack of sufficient income to maintain an adequate standard of living

“Individuals who are most marginalised will carry the burden”

Further details: Lucy Burns l.burns@unsw.edu.auTHANK YOU