Mental health articles

Case study on substance misuse: Joan for old people

The following case study highlights some of the issues to consider when an older person has a drink problem. Joan was a sprightly 74-year-old Scottish woman who had lived in London for many years. She approached the substance misuse service for help with her drinking, but found attending a daunting prospect. At the selfreferral clinic the waiting area was crowded with an array of drug users and drinkers. Joan had to wait for some time before being seen and found the environment intimidating. It appeared that there were several factors contributing to Joan’s drinking.

First, she was lonely. Her husband had died some years earlier and although the marriage had not been happy, Joan had spent several years being his carer as his health had been poor. Joan’s sisters, with whom she had a good relationship, lived in Scotland. She had two daughters, one lived locally, the other about 60 miles away. The one living nearby had ‘problems of her own’. Rather than being a support she was more of a burden. She would phone Joan late at night and spend an hour or more talking about her difficulties. Joan felt unable to terminate the conversations and was reluctant to involve her other daughter as she had a family to look after, ‘a life of her own’, and was preparing to move abroad. Joan’s dog, who had been with her for many years, had recently died. She felt an intense sense of loss and not having the dog to take for a walk meant that her familiar routine was lost. Moreover, Joan lived in a ground-floor flat and without the dog felt fearful for her safety, and was not sleeping well. Her flat was on an estate where many other older people were living. Joan was younger and less frail than the others so they looked to her for help and support. While Joan was willing to help people out, at times their demands seemed excessive and she found it difficult to refuse their requests.

Joan could go for several weeks and not drink at all but when her situation got on top of her she would buy a bottle of Scotch with the intention of having a glass or two, but once she started it was difficult to stop. It was not unusual for her to drink over half a litre of Scotch. The next morning she would feel physically unwell and guilty about her drinking. One way of dealing with this was to drink again, and in this way a binge would begin. When drinking heavily Joan would not eat. During one episode of heavy drinking Joan fell and was found on the floor by a relative who happened to be in the area and had called to see her. Fortunately, she was not badly hurt. On some occasions when Joan had been drinking heavily her GP would prescribe diazepam so that she could detoxify safely. Joan knew the dangers of taking diazepam and drinking so if she felt unable to maintain abstinence from alcohol she would not take the diazepam. This had resulted in her acquiring a store of diazepam. Sometimes when Joan had been drinking for a few days she would become depressed and feel suicidal. The daughter that lived nearby would usually become involved at these times. She contacted the mental health services and insisted that her mother be admitted to hospital. Joan was admitted to the elderly mental illness ward on a number of occasions. Once she had detoxified from alcohol her depression lifted and she returned home. As she did not have a formal psychiatric diagnosis she was not followed up by the mental health team but the substance misuse team nurse did keep in contact with her. While Joan’s circumstances are unique to her, many features of her situation are common to other people who develop drink problems in later life. Lack of routine or day-time structure, bereavement, loneliness, a sense that life is coming to an end and has little to offer can all be factors. Nurses need to be alert to the possibility of substance misuse being a factor in the presentation of older people and not think of it only as a younger person’s problem.

While substance misuse services may have a role to play, older people should be able to obtain help in a setting which is easily accessible and non-threatening to them. After her initial presentation Joan was seen at a clinic based at the local hospital and, on some occasions, she was seen at home.

Tags: case study, substance misuse