Research Article - (2015) Volume 23, Issue 3
Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Norway
Helvik A-S
Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Norway
Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim
St Olav’s University Hospital, Trondheim, Norway
Engedal K
Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Norway
Ulstein I
Old-Age Psychiatric Department, Oslo University Hospital, Norway
Sørlie V
Lovisenberg Deaconal University College, Oslo, Norway
Background: Studies published the past ten years revealed that use and misuse of alcohol and psychotropic drugs is an increasing phenomenon among older people (aged 65 years and above). Aim: The objective of the study was to investigate general practitioners’ (GPs) experiences and reflections on use and misuse of alcohol and psychotropic drugs among older people, and to what extent this is an issue in the treatment of them.
Method: Qualitative interviews with 11 GPs were performed during 2013 and 2014. The data were analysed by using the phenomenological hermeneutic method.
Findings: The first theme that arose was the GPs’ experiences with and reflections of the older people’s situations and their use and misuse of alcohol and psychotropic drugs. This theme included three subthemes: older people’s situations, older people’s alcohol use, and older people’s psychotropic drug use. In the second theme, the GPs described their practice and attitudes towards use and misuse of alcohol and psychotropic drugs among older people. It included the subthemes: assessment of alcohol use and prescription of psychotropic drugs.
Conclusion: The study revealed that the informants experienced numerous older people who have existential needs and mental health problems; such needs are not necessarily handled adequately by the GPs, their next of kin, or society. Alcohol use or wish for psychotropic drugs among older people is a possible way to minimize these difficulties. The GPs had a lack of routine concerning the assessment of alcohol use, whereas they were more restrictive when prescribing psychotropic drugs than earlier.
alcohol, general practitioners, geriatric psychiatry, interviews, misuse, older people, psychotropic drugs, qualitative studies.
‘How this fits in with quality in primary care’
What do we know?
Use and misuse of alcohol and psychotropic drugs is an increasing phenomenon among older people. Psychotropic drugs are found to be the most prevalent misuse problem of older people in many countries, followed by alcohol misuse. Any intervention that could increase the knowledge and attention about the misuse of alcohol and psychotropic drugs among older people can contribute to the reduction of an unhealthy consumption.
What does this paper add?
The GPs had a lack of routine for assessing alcohol use, but are more restrictive when prescribing psychotropic drugs than in years past. Several older people have existential needs and mental health problems, needs that are not necessarily handled adequately in the community care. One way to minimize these difficulties among older people is alcohol use or psychotropic drugs.
Until recently, little research has been conducted on the use and misuse of alcohol and psychotropic drugs among older people aged 65 years and above,[1] although it is an increasing phenomenon among older people.[2,3] The use of alcohol, especially, is expected to become an increasing health issue in the years to come because the coming generation of older people has another view regarding the use of alcohol compared to past generations.[2] Various terms such as dependency and harmful use are used to describe use and misuse of alcohol and psychotropic drugs.[4] In the present study, we will use the term misuse.
The recommended guideline for use of alcohol in old age in the United States is one alcohol unit a day, or one drink a day,[5] but discussions among researchers about what constitutes a safe limit for older people are ongoing.[2] Harmful consequences of alcohol misuse in old age include increased risk of falling, poor nutrition, and impaired cognition.[4] Such negative effects can, in turn, increase the risk of dependency, morbidity, and mortality.[2,3]
Furthermore, it has been reported that misuse of psychotropic drugs is prevalent among older Europeans.[4] Psychotropic drugs were also found to be the most prevalent misuse problem of older people in America, followed by alcohol misuse.[6] To establish limits for misuse of psychotropic drugs which have a dependency potential is hard since the DSM-5 manual’s[7] definition of misuse is broad. In addition, one has to remember that the use of psychotropic drugs may be inappropriate even if it is not problematic or considered to be misuse.[8] The prescription may be related to a less restrictive prescription policy by the general practitioners (GPs).[9] Another reason could be changes in modern society, such as an increased prevalence of psychological difficulties among vulnerable groups like older people.[2]
In Norway, the knowledge about older people’s use and misuse (or even abuse) of alcohol and psychotropic drugs is limited,[10] but an increased consumption the last decades of alcohol and intake of psychotropic drugs are documented.[9,11] The older people account for about half of the consumption of psychotropic drugs in the country.[12] In Norway, guidelines for diagnosis, treatment, and follow-up of individuals’ misuse disorders, and co-morbid mental illnesses, do exist, but are not adapted to the specific needs of older people.[13] To provide information, finding effective services and treatments for reducing the misuse could be of importance in promoting health among older people.[9] Therefore, we assume that any intervention that could increase the knowledge and attention about the misuse of alcohol and psychotropic drugs among older people could also contribute to the reduction of an unhealthy consumption. Such intervention could be provided by GPs, but we do not know how the GPs regard use and misuse of alcohol and psychotropic drugs among older people. Nor do we know if this is an issue in the GPs’ assessments and choice of treatments, or to what extent they refer older people to a specialist for care services. Therefore, we desired to conduct a study aiming to investigate GPs’ experiences and reflections on use and misuse of alcohol and psychotropic drugs among older people, and to what extent this is an issue in treatment.
Design
A qualitative design with a phenomenological-hermeneutical method, influenced by Ricoeur’s philosophy, was conducted.[14] This method is described by Lindseth and Norberg,[15] and is suitable for describing the meaning of lived experiences in interview texts.[15,16]
Participants and setting
The heads of the GPs’ local associations in eight urban and rural municipalities in southern and western Norway were informed about the study by mail and telephone, and asked to recruit GPs as participants. The heads of these municipalities were chosen for practical reasons, such as the pressure of time and cost of data collection. The heads were asked to recruit GPs working in their jurisdiction area, but no restrictions were put on age, gender or duration of work experience of the GPs that were wanted. All the 11 first responding GPs were included. They came from seven urban and rural municipalities. The participants had heterogeneity and variation by age, gender, and experiences of work. Four woman and seven men, aged 29 to 65 (mean 48) years, were interviewed in 2013 and 2014. They had work experiences as GPs from four months to 35 years, and nine had a specialty in general medicine. None had specific work experiences with misuse, three had experience from psychiatric hospitals, and one had worked in a geriatric unit for a year.
Data collection
Seven of the individual interviews took place at the informants’ office, three were carried out by telephone, and one took place in a meeting room at a hotel. The first author carried out nine of the interviews, and the one co-author two of them. None of the interviewers were GPs or worked in the chosen municipalities. The interviews lasted from 15 to 45 (mean 30) minutes and were tape-recorded. A professional typist transcribed the interview verbatim within 14 days of the interview. As a quality control of the transcripts, the first author listened to the tapes while reading the interviews.
A way to understand the GPs’ experiences and reflections is by studying their narratives regarding their experiences. Furthermore, the perspective of the interviewees is best revealed in stories where the informants use their spontaneous language in the narration of events.[17] Narratives give us a better understanding of life and experiences than that provided by concepts, tables, and figures. They touch us differently than factual knowledge, and therefore, give us a better understanding of actual experiences.[16] The purpose of the interviews was to obtain as many rich narratives as possible, without interrupting the GPs, by tying questions to their topics and reflections. Mishler[17] claims that most informants will tend to tell stories when asked open questions. Two open-ended questions were asked: “What is your experience of use and misuse of alcohol and psychotropic drugs among older people, and to what extent is psychotropic and alcohol use and misuse focused on in the treatment?” The interviewer asked spontaneous follow-up questions throughout the interview, such as: “You said…Can you tell me more about this”, or “How do you handle it?” After 11 interviews little new information was uncovered and the data collection ended.
Analysis
The content of the interviews was continuously discussed among three of the authors, and all of the authors contributed to the final analyses in order to reach a consensus. A phenomenological-hermeneutic method developed for the purpose of researching life experiences[14,15] was conducted. The method has the advantage of shifting dialectically between explanations and understanding.[15] The interpretation implies a dialectic movement between the text as a whole and parts of the texts, and consists of three steps as described by Ricoeur,[14] Lindseth and Norberg.[15]
The first step was a naive reading of the transcribed interviews. They were read several times to establish an impression and achieve a sense of the whole. A prior condition is that the text is read so that the nuances are defined as the reader allows the text to talk to him or herself. The analysis then moved towards a phenomenological understanding, where the reader is allowed to be touched by the narratives. The naïve interpretation and understanding of the text reveals the direction for the structural analysis.[14,15] The structural analysis, (the findings), was the second step of the analysis. A variety of examinations of parts of the text is included to validate or refute the initial understanding obtained from the text.[14,15] The text was divided into meaning units, which consists of parts of a sentence, and sometimes several sentences that were condensed into themes and subthemes aiming to explain what the text says. The third step, called the comprehensive understanding, (the discussion), is an in-depth interrelation and understanding that was developed by reading the text as a whole, taking into account the authors’ pre-understanding, naive reading, the structural analysis, and relevant theories and previous research.[14,15]
Ethics
This study follows the ethical principles outlined in the revised Helsinki declaration[18] and was approved by the Regional Committee for Ethics in Medical Research, Southern Norway. The participants received oral and written information and gave written consent before the interviews. The researcher had no influence on their work and participation was volunteering. Person-identifiable data have been deleted from all stored transcripts to provide confidentiality.
Findings
Two themes and five subthemes were revealed by the data and are presented in Table 1.
The GPs’ opinion of older people’s alcohol and psychotropic use
Older people’s situation
The informants experienced that many of their older patients were lonely, and therefore, used alcohol and asked for psychotropic drugs to reduce their strain. Structural changes in their lives and in society, such as the children having moved out or were too busy with their own lives, loss of friends, dependency because of poor health, and few meeting places for older people, were seen as reasons for loneliness. The GPs perceived that older people belong to a generation with a lesser degree of openness about their life situation than younger people, but also that they are pushed away from society. Moreover, the informants said that older people were more often ashamed and less open about mental health problems, and use of psychotropic drugs and alcohol. Older people are a vulnerable group of people, of whom we know too little about their needs for social and health services. As one of the informants said: “Lack of knowledge among health professionals about older people’s mental health was also a reason why it is easy for us GPs to resort to psychotropic drugs. That is a solution that perhaps is not the best, but it is difficult sometimes to sort out the older patients’ problems such as traumatic experiences, losses, or perhaps addiction to psychotropic drugs after many years of use”.
The GPs added that relatives could sometimes be against an older person’s wish to change the use of alcohol and psychotropic drugs, because they sometimes think that the older person will have a better quality of life by continuing the use of alcohol or psychotropic drugs. However, the opposite could also be the case, as one told, “Sometimes relatives, neighbors, or friends are worried because of the misuse of alcohol, and comes here and tells me”.
Older people’s alcohol use
The informants experienced cultural differences with regard to use and misuse of alcohol among older people, and that there seemed to be a more hidden misuse in big cities. In the GPs’ opinions, people drink more alcohol today, as it is more socially accepted among older people. They meant that this fact could indicate an increase in the use and misuse of alcohol. The informants did also express that the older patients trivialized their use of alcohol, and one informant said: “Older people talk very little about the healthy use of alcohol, or that they simply have two glasses of wine in the evening. That I rarely hear, but very often I think they are trivializing their use. They tell that they just do not drink more than what is usual, but then it is hard to get in on what is usual”.
Older people’s psychotropic drug use
The informants said that today it is mainly the older patients who request psychotropic drugs, and the most frequent request is for sleeping pills. Also, older patients often trivialized their use of this kind of drugs, as one informant expressed: “Sometimes they tell me that they have lost the psychotropic drugs in the wash pot, or they request more psychotropic drugs just at the end of a consultation with me”.
The informants meant that many older patients seem be anxious regarding not falling asleep, and they would definitely not withdraw the use of sleeping pills in patients who have used such pills for many years. Older women more often requested psychotropic drugs than older men, whereas they were sceptic to anti-depressants. Furthermore, the GPs experienced that older people had little knowledge about the possible sideeffects of sleeping pills. As one expressed: “Most of the older patients trivialize their use of sleeping pills and look at the use as something harmless, and they do not have knowledge about the risks, such as a higher fall tendency”.
According to the GPs, older people also quite often share experiences about positive and negative effects of psychotropic drug use, and sometimes they also shared drugs with other family members and friends. Women seemed to cope better with crises and loneliness than men, the GPs said. Even so, GPs often focus too much on older peoples’ physical health, and not on mental health issues in the consultations. One informant expressed: “The GPs do focus very little on old peoples’ composed problematic history of illnesses and loneliness”.
The GPs’ practice
All the informants had experiences regarding their patients’ use and misuse of alcohol and psychotropic drugs. The GPs’ attitudes to prescribe psychotropic drugs have changed, and is more restrictive today compared to some decades ago. Still, in the GPs’ opinions, there is too little focus on older people’s mental health and referral to available psychiatric specialist health services, which was referred to as the main reason for the high prescription rate of such drugs. However, they generally found it difficult to stop the prescription of psychotropic drugs, because they assumed that many older people were addicted to psychotropic drugs caused by many years of use as one said: “Many of the older patients have used psychotropic drugs for 30 or 40 years, and some of them started with the use of such drugs in connection to an illness or hospitalization. It is very difficult to motivate them to stop with the use of psychotropic drugs”.
Assessment of alcohol use
The interviewed GPs had very little focus on assessment of alcohol use of their older patients. They asked people in general about tobacco use, and felt that they should do the same about alcohol use in the future. Maybe a brochure as a reminder would be of help to more often assess alcohol use. One of the informants expressed it in this way: “Being a GP, you have to learn new things all the time, and that is fun. So my lack of focus on assessing alcohol use, that is a bit embarrassing”.
The GPs expressed that it was demanding to assess alcohol use, because it was considered a matter of privacy. They felt it was disempowering and insulting to ask older patients about their alcohol use, and therefore, much easier and less insulting to assess alcohol use by analyzing liver enzymes in blood. The GPs shared that they sometimes gave advice to the patients about alcohol consumption, especially when the older patients had sleeping disturbances or a serious physical disorder. As one of the informants said: “We give advice about alcohol use sometimes if the patients have diabetes or infections. Then we perhaps ask a bit snotty about what they are going to do on their holidays”.
Most of the GPs shared that they did not know for sure about the recommended alcohol units for older people, but they were aware of gender differences in the misuse of alcohol. As one expressed: “Of those few older patients I know that misuse alcohol, the alcohol misuse is more a hidden misuse, mainly among older women. The few older male patients I have with alcohol misuse are known, and are also often linked to driving and drunkenness”.
Prescription of psychotropic drugs
The informants referred to an action taken by the Ministry of Health and Care. The sales of some psychotropic drugs were stopped, and since then a reduction of unhealthy use of psychotropic drugs has taken place. Another action that was referred to and emphasized as positive by the informants was that the pharmaceutical industry is no longer allowed to advertise for drugs at congress and other meeting places. The informants also expressed that during the past years, the knowledge about the effects of psychotropic drugs has changed, and today they have more focus on the side-effects and lack of effects of the drugs. As one said, “We think differently about the effects and use of drugs today than we did some years ago”.
Furthermore, the informants expressed that it was an important issue to consider older patients’ age against quality of life and side-effects before prescribing psychotropic drugs or continuing the prescription. The informants said that older people, in general, use too many psychotropic drugs, which could be risky for their health and could increase falls, as well as have an interaction with other drugs. As one of the informants expressed: “We are good at prescribing new medication, but not at withdrawing medication. The good GPs are better on withdrawing medication”.
The GPs stated that psychotropic drugs with better effects, shorter half-life times, and fewer hangover symptoms were now available on the market, which could reduce the negative side-effects. They further argued that the new psychotropic drugs with more favorable effects and fewer side-effects could be the reasons for a lower threshold among GPs to prescribe the newer psychotropic drugs. As one said: “The low threshold of prescribing drugs continues when the medication is not that strong. It is very easy today to prescribe sleeping pills”.
On the other hand, they said that they avoided writing prescriptions for some drugs to prevent addiction in the patients. One informant said: “If I cannot get the patient to stop the use of such drugs, I try to keep the prescription as low as possible, and of course certainly not increase the dose”.
To avoid or reduce prescriptions of psychotropic drugs, the GPs told that they often discuss this issue with colleagues, but still, it is a demanding problem. One informant expressed: “I think that it is demanding when the patient [older person] just comes and wants drugs. When I try to avoid further use by telling him/her that I will stop the prescription, the older person sometimes suggests that I am not a kind person, or a weird and strict person. Those who are most unsatisfied or disappointed switch to another GP”.
They said that many GPs do not take actions if a patient is addicted to a drug. They further argued that it is not realistic to refer older patients that are addicted to psychotropic drugs to a specialist with psychiatric health care services. They emphasized that it was better to prevent older people from becoming addicted to psychotropic drugs than to stop drug use among those who are already addicted. In addition, they also claimed that stopping the prescription of psychotropic drugs that the patient was addicted to could be harmful because of risk of serious withdrawal symptoms. One of the informants said: “There is no one that can help the old patients and follow up with them after their withdrawal from psychotropic drugs, which can have serious side-effects like abstinences. Older patients are supposed to be included and helped with their addiction in the psychiatric health care service”.
The purpose of this study was to investigate the GPs’ experiences and reflections of use and misuse of alcohol and psychotropic drugs among older people, and to what extent this is an issue in the assessment and treatment. To contribute to a broader understanding of GPs’ experiences and reflections on this topic, the findings will be discussed in the order in which the themes are organized (Table I).
In their daily practice, the physicians experienced that the life situation of many older patients are difficult, and that they are a vulnerable group with several health difficulties. Several feel lonely and pushed aside, and this is partly caused by changes in society. It is well-documented that older people are a vulnerable group who suffer from loneliness.[2,3] The GPs have experienced that many older people have existential needs and mental health problems, needs that are not necessarily met or handled adequately by them, their next of kin, or society.
The GPs expressed that use of alcohol or a wish for psychotropic drugs among older people is a possible way to minimize their difficulties. The GPs also said that it seems that women cope better with crises than men, but even so, women request more psychotropic drugs than men do. According to the interviewed GPs, there was more shame and less openness among older people linked to existential and mental health difficulties, as well as use of alcohol and psychotropic drugs. The women’s alcohol misuse was a more hidden problem. The older patients often trivialized and minimized their use of psychotropic drugs and alcohol. In line with the present study and other studies, substance misuse is a taboo or stigmatized topic, described as a private issue and being a “silent epidemic”.[19,20] Even so, older people are more likely to seek care compared to younger people, and thereby misuse could be revealed.[3] In a report by Crome and co-workers[2] it is documented that treatment of misuse among older people has a slightly more positive outcome than treatment among the younger ones. However, as the GPs experienced, relatives sometimes were against reduction of psychotropic drugs or alcohol use. Action to reduce alcohol use or use of psychotropic drugs could be difficult to carry out.[19]
In line with previous research, the GPs were well-aware of the frequent use of alcohol and psychotropic drugs in older people.[2,3,9,21] The frequent use of alcohol and psychotropic drugs in old age is of national interest, and in the last few years, health politicians have discussed this topic.[22] However, in Norway, the guidelines for use of alcohol in old age exist but are not adapted to the specific needs of older people, such as in several other countries.[2,5] There is a lack of focus on this topic in the Norwegian society. In line with our study, Draper and colleagues[23] point out that geriatric patients in Australia are a group with an increased risk of misuse of alcohol and psychotropic drugs, but the topic has a low priority in Australia, as well. It can also be argued that it may be hard to define dependency potential since the DSM-5 manual’s[7] definition of alcohol and psychotropic drug misuse is broad. Payne and colleagues[24] have also pointed to the lack of a clear definition of psychotropic drugs misuse as a substantial barrier to diagnose and treat psychotropic drug misuse.
The study shows that GPs lack routines for assessing alcohol use of their old patients, partly because they considered the topic as a matter of privacy. The lack of assessment routines is found also in other studies.[2,19] The GPs saw it easier and less insulting to assess alcohol use by analysing liver enzymes in blood. The GPs thought screening for alcohol use would have been easier if the negative consequences of alcohol use in older persons had been a topic in society, like nicotine use has been. In this study, the GPs expressed little knowledge about accepted alcohol units for older people.
The informants said that assessing alcohol should be given a broader focus in the years to come in order to enable early identification of misuse and treatment. Another study stated that assessing alcohol use should be done in relation to screening for depression, anxiety, and personality disorders in older persons[25] and is in line with the general Norwegian ROP-guideline.[2] This is in line with the review of Rosen and colleagues,[1] who pointed out that practitioners treating health problems, including mental health problems, are at a disadvantage in accurately identifying and treating the problems without a proper understanding of the use and misuse of alcohol.
The GPs expressed that the main reason for the high prescription of drugs for older people was caused by a lack of knowledge and focus on older people’s mental health. A lack of exact knowledge on a topic can lead to overtreatment, which is also documented in another study.[26] In addition, the study revealed that it was not only lack of knowledge that contributed to the high prescription of psychotropic drugs, but was also the GPs’ scarce possibility of referring older people to psychiatric specialist health services. This is also in line with the findings of Nordam and colleagues,[27] who stated that there is a lack of treatments and health services for older people. However, our study shows that over the last few years, the knowledge about the effects of psychotropic drugs has increased. Today, GPs have more focus on the side-effects than possible effects or lack of effects of these drugs. In a public health perspective, this can be explained as a change from a reductionist understanding of health and is much more in common with the old understanding of public health. Additionally, the new understanding of public health, so called new public health, finds a holistic focus is more common.[28]
Because of increased knowledge, GPs today are more restrictive when prescribing psychotropic drugs. Another study shows that withholding this kind of treatment is a demanding work task for physicians.[26] Fear of harmful withdrawal effects and abstinences was also a reason for not stopping the prescription of psychotropic drugs the patients were addicted too. However, in general, they tried to keep the doses as low as possible. In a study by Culberson and Ziska,[29] it is stated that such practices may decrease the risk of misuse and dependency, but on the other hand, fear of abuse often results in a failure to adequately treat anxiety, pain, and insomnia. Another study points out that there is a need in primary care to focus on the indication and the use of drugs in general, while the psychiatrists need to look at how to focus and treat patients of older ages.[9]
Also revealed in this study, the action taken by the Ministry of Health and Care to stop the sales of some psychotropic drugs and limit advertising for drugs has been of help to avoid prescription overuse and to reduce the amount of drugs taken. Our findings show that the possibility to have a discussion with other colleagues on how to reduce the prescription rate of psychotropic drugs to older people was of great value. To have discussions with colleagues about demanding work tasks was also found to be of great importance in the study by Sørlie and co-workers.[30]
Methodological considerations
Lack of knowledge about GPs’ experiences with and reflections on alcohol and psychotropic drug use among older people motivated us to use a qualitative method in the present study. This method is helpful in providing knowledge of phenomena in areas where little is known.[31] To provide the qualitative accounts of life world, narrative interviews and a phenomenological hermeneutic method of interpretation were utilised.[14,17] The present study used a purposive small sample of 11 GPs who came from seven different smaller and bigger municipalities. The sample offered a wide range in terms of age, reflections, and experiences with the use and misuse of alcohol and psychotropic drugs among older people. We hold the opinion that the purposive sample helps to validate the results.[31] Also, according to Sandelowski,[32] sample size in qualitative research should be large enough to achieve a variation of experiences and small enough to permit deep analysis of the data. The informants were interviewed individually, which provides varied perspectives. A solid knowledge base has also been presented in the text in order to contribute to trustworthiness. The data were also analysed and discussed by several of the authors in order to reach conclusions.[31] In addition, the authors have different health-care and medical backgrounds (nurse and psychiatrist), and experience from both mental and somatic health-care. This provides varied perspectives and a solid knowledge base.
As this present study is qualitative in nature, it is not reasonable to discuss the concepts of validity, reliability, and generalizability in a traditional consensus. The few informants chosen in qualitative research projects are insufficient to allow findings and conclusions to be generalised. The findings do, however, ensure and strengthen the representability in relation to transferability, as the findings allow in-depth insight in the phenomena being studied. It can, therefore, be stated that qualitative research projects show a high content of validity.[33] The findings may contribute to a better understanding and development of public information, in general. Hopefully, the findings can also be used to improve social and health care services for older people in order to reduce the use and misuse of alcohol and psychotropic drugs among older people.
The study revealed that the GPs had a lack of routine for assessing alcohol use, but is more restrictive when prescribing psychotropic drugs than in years past. The participants experienced that several older people have existential needs and mental health problems, needs that are not necessarily handled adequately by them, their next of kin, or society. Alcohol use or wish for psychotropic drugs among older people is a possible way to minimize these difficulties.
