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Older patients

One more revolution

Author: Amanda Lyons

Baby boomers continue to challenge conventions, even as they enter their golden years. 

A female patient, 72 years old and a widow, comes in for a consult and tells her GP, ‘I’ve met someone and we want to have sex. The only problem is, I haven’t had sex for 15 years. Is there anything I should do?’

A research expert on addiction education and training is contacted by the managers of an aged care facility who, somewhat baffled, tell her, ‘We know people here are using cannabis. We can smell it.’

These situations and others like them are only going to increase as the baby boomer generation – generally defined as those born between 1946 and 1964 – continues to age and changes notions of the lives older people want to lead.

‘The baby boomer ageing cohort are very different to previous generations of older groups,’ Prof Ann Roche, Director of the National Centre for Education and Training on Addiction at Flinders University, told Good Practice. ‘They’re very assertive, they’re clear about quality of life and what they expect and demand, and they’re not going to be patronised.’

Dr Keri Alexander, a former GP who now works as an addiction specialist, believes the baby boomers are going to revolutionise ageing, just as they revolutionised youth.

‘They’ve rewritten everything through every life-stage, and I’m convinced they’re going to rewrite ageing and living well in retirement and the old, golden years, and challenge our thinking on that like they have throughout everything else,’ she told Good Practice.

So what will this revolution in ageing mean for the GPs who are helping to provide care to baby boomers? How will they have to change their ideas of what an older person might represent? 

The dating game

Research is clear that the sexual behaviours in older people, as Bob Dylan would say, are a changin’.

‘Older Australians are more sexually active, with more partners, than they have ever been before,’ Dr Lara Roeske, GP and Chair of the RACGP Specific Interests Sexual Health Medicine network told Good Practice.

Greater social acceptance of divorce and remarriage has driven changing patterns of partnering and re-partnering, while the ubiquity of the internet has dramatically increased opportunities to meet new partners – and that goes for all age groups.

‘The fastest-growing demographic accessing online dating sites is older Australians, and recent research tells us that older internet dates become sexual much faster than younger internet dates,’ Dr Roeske said.

While the ever-increasing availability of internet dating and mobile apps has opened previously unavailable avenues for older people to meet people, it has also led to another, less desirable increase – namely in the rates of notifiable sexually transmitted infections (STIs).

‘Part of that is that more people are getting tested, so that’s a good thing,’ Dr Deborah Bateson, Medical Director at Family Planning, New South Wales, and Co-Chair of the Australasian Sexual Health Alliance, told Good Practice. ‘But with a lot of STIs we only see the tip of the iceberg, so we’re only counting what we actually test. We know there’s a lot of undiagnosed infections like chlamydia and gonorrhoea.’

Dr Bateson’s research has revealed a variety of contributors to these increases, including that older men and women are less likely to use condoms in new relationships.

‘Often, older people just have not been exposed to that school-based sex education. In fact, it probably wasn’t even there,’ Dr Bateson said.

‘Most safe-sex campaigns are aimed at younger people, so I think there’s a lack of information and awareness about the risks of STIs with new partners for older people. Perhaps there’s also some misinformation; for example, that you can tell if someone’s got an STI, not realising that most STIs have got no symptoms.’

There can also be problems in communication between partners.

‘There may be a bit of embarrassment about that conversation, negotiating condoms, and I think that’s particularly the case for women. We know they can still find it very challenging to actually buy and carry condoms, and if no-one’s got one, that can be difficult,’ Dr Bateson said.

A lack of concern about pregnancy is also a significant disincentive for using condoms among older heterosexual people.

‘We know from the research that prevention of pregnancy is higher up on people’s concerns than preventing STIs,’ Dr Bateson said. ‘So when that risk is gone, that can lead to lower condom use.’

Dr Bateson emphasises that ‘STIs don’t recognise age’, and it is therefore important for GPs to keep this in mind when they are seeing older patients. Sexual health is a topic that can be difficult for patients to bring up in consults, especially if they are older, so opportunistic screening can be a useful approach.

‘When women come in for cervical screening, that’s an ideal time to raise the issue,’ Dr Bateson said. ‘Another useful time is when you know a patient is preparing to go off travelling somewhere; it does seem that there’s more risk-taking when people are away on holiday.

‘Also, if your patient is separated or divorced. We know that recently separated or divorced people who are meeting new partners may be more susceptible to unsafe sex.

‘It’s just about raising the topic non-judgementally. Patients might not be that keen to disclose straight away, but then they may come back and make another consultation.’

Above all, it’s about treating older patients with kindness and respect and recognising that older people have not necessarily withdrawn from the ‘romantic’ side of life. It is also about GPs feeling confident in discussing the topic.

‘GPs just need to be unfazed and seek help if they need a bit of support about how to discuss sexual health with older patients, because it’s really important to make people feel comfortable around these sensitive areas,’ Dr Bateson said. 

Changing habits

This year’s National Drug Strategy Household Survey revealed some surprising information on rates of risky drinking: they are declining in Australia, except among people aged 50 years and older.

Additionally, the largest percentage increase of drug misuse in 2013–16 was among people aged 60 and older, and was mainly focused on prescription drugs. People over 50 also showed higher rates of illicit drug use than their younger peers, particularly with cannabis.

‘This upward trend with older age groups was particularly striking and something that we hadn’t seen before,’ Prof Roche said. ‘We are in a most unusual period in time.’

Statistics show that GPs are very likely seeing older people with drug and alcohol issues in their practices already.

‘We’ve got one in four people in the 50–59 age group drinking at what we’d define as a risky level at least once a month,’ Prof Roche said. ‘And then amongst the 60-year-olds it’s one in five, so that’s a large-ish number.

‘From a primary healthcare, GP perspective, this is a substantial proportion of the patient population they would be seeing.’

Dr Alexander said this means practitioners may need to ditch any preconceived notions they might have about older people’s lifestyles.

‘Just because someone is over the age of 65 doesn’t mean they’re immune to having a drug or alcohol problem, or don’t use illegal drugs,’ she said. ‘It’s really important for us health professionals to be open-minded.’

After experiencing more contact from aged care providers encountering drug and alcohol use in their facilities, Prof Roche and her team at Flinders University began conducting research into the phenomenon. They identified three different groups of alcohol and/or drug users among older people.

The first group is the ‘maintainers’.

‘These are people who had a lifelong pattern of drinking alcohol or using other illicit drugs that they maintain into older age categories,’ Prof Roche said. ‘We don’t metabolise alcohol or other substances as efficiently as we get older, so what might have been a non-problematic level or pattern of use in earlier years can become problematic later. People are also likely to be taking other medication where alcohol, particularly, would be contraindicated.’

The second group is the ‘survivors’.

‘These are people who had a problem with things like heroin and have been on methadone or opioid substitution programs for a long time,’ Prof Roche said. ‘We used to talk about people either maturing out or dying early from their alcohol and drug use, but there is a sub-population who, through improved healthcare and better drug regimes, have survived longer into older age than would have been expected.’

Dr Alexander identifies the growing incidence of prescription opioid addiction among older patients as a particular concern, as it can cause harms ranging from increased risk of falls to death by overdose. It is also leading to an increased number of ‘survivors’ requiring support in aged care.

‘I’ve been involved in a few cases so far where elderly residents on the methadone program have had to go into nursing home care,’ Dr Alexander said. ‘Historically that’s been very rare in that older group, but I suspect we’re going to see a massive growth of that because of the prescription opioid dependence.’

The third group is the ‘reactors’.

‘This group may be reacting positively or negatively to changing circumstances such as changes in living arrangements, loss of a partner, loss of role identity through retirement,’ Prof Roche said. ‘They develop or increase the use of alcohol or drugs or change their patterns of use in reaction.’ 

Prof Roche believes these categories can be very useful for GPs.

‘It can give a sense of what’s relevant for that person or what’s happening in their lives, so they can give supportive and appropriate advice about safer and lower risk patterns of consumption,’ she said.

Because the issue is so common, Prof Roche feels it is helpful for GPs to maintain a high index of ‘suspicion’ in relation to drugs and alcohol when treating older patients. Several common flags or indicators may also prove helpful.

‘Standard things like increased blood pressure, for instance. That’s a really cardinal indicator of potential higher levels of alcohol consumption,’ Prof Roche said.

‘Depression, which can become quite common in older people, can often be associated with alcohol consumption. Get people to stop their alcohol consumption for a couple of weeks to see whether it really is an endogenous depression or whether it’s really a function of the alcohol.

‘A really common presentation in primary care for older age groups is disturbed sleeping pattern. People’s sleeping patterns just change as they get older, but if you’ve been drinking a bit excessively it’s highly likely it will help you fall asleep but you’ll get early waking as a result.’

Dr Alexander suggested a quick, easy and respectful way to screen patients for alcohol and drug issues.

‘Ask them about tobacco first, as it’s less likely to cause offense because it’s legal, common and relevant to health,’ she said. ‘And then alcohol because, again, that’s legal, common and relevant to health. And then cannabis, because even though it’s across the legal–illegal divide, it’s relatively common so it’s less likely to cause offense.

‘And then, if someone doesn’t use and has never had a problem with any of those, ask, “Any other drugs?”’

Dr Alexander also said it can be extremely helpful for GPs, and can help them feel more comfortable in handling these issues in consults, if they know how to provide patients with further information and assistance.

‘If a problem is identified, it’s really handy to offer to refer the patient to a drug and alcohol service for more thorough assessment and screening, and to discuss treatment options,’ she said.

‘But if they decline that, it’s perfectly reasonable to give them the phone number for the state drug and alcohol service and recommend they contact that to discuss it further.’

When it comes to treatment, Prof Roche said there is another preconception about older people that needs to be challenged – the idea that they can’t change their behaviours.

‘The evidence is very clear that if they have a substantial problem, older people do very well in response to both early intervention and advice, but also in treatment programs,’ she said.

‘So that’s another misconception, “Can’t teach old dogs new tricks, it’s too late to change”. The evidence simply doesn’t support that at all.’