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Alcohol and aging: a multimethod study on heterogeneity and multidimensionality
Umeå University, Faculty of Social Sciences, Department of Social Work. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).ORCID iD: 0000-0002-4378-6803
2023 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Alkohol och åldrande : en multimetodstudie om heterogenitet och multidimensionalitet (Swedish)
Abstract [en]

Background and Objectives: With an ageing population, the number of older persons with substance use problems, particularly problematic alcohol use, is increasing. Despite grow­ing recognition of the negative consequences of problematic alcohol use on older persons, there is a dearth of knowledge about the alcohol use profiles and the dimensionality of alcohol problems in older people. Moreover, little is known about older persons’ experi­ences and perspectives on alcohol use in relation to their ageing and their personal goals regarding treatment and recovery. This thesis aimed to (i) describe the characteristics of older persons who accessed municipal substance use treatment and care services (addic­tion services) and to investigate their future hospitalization; (ii) examine the heterogeneity and multidimensionality of problematic alcohol use among older persons; and (iii) to shed light on the experiences and perspectives of older persons regarding ageing, alcohol prob­lems and recovery.

Methods: For studies I-III, municipal Addiction Severity Index (ASI) assessment data (between 2003 and 2017) from adults aged 50 years and older were used to select the study samples. Generalized linear regression models investigated hospitalization related out­comes among 3624 older persons in Study-I. In Study-II, a latent class analysis was applied on ASI data from 1747 individuals with alcohol problems. Study-III linked the ASI data from Study-II to hospital discharge and mortality data forming time-to-repeated-event dataset; Andersen-Gill regression model with a robust variance estimator was used for the analysis. Study-IV applied qualitative content analysis on interview data from ten older persons re­cruited from a specialist outpatient clinic for alcohol treatment. 

Results: Nearly three-fourth of older persons assessed for substance use severity at municipal addiction services were later hospitalized (Study-I). Individuals diagnosed with substance use disorders, psychiatric or dual diagnoses had more cumulative hospitalized days, higher rates of hospital readmissions, and shorter time to first admission following an initial ASI assessment at municipal addiction services (Study-I). Five distinct groups of older persons with comparable alcohol problem severity but with variation in onset age, psychiatric comorbidities, polysubstance use, social support and gender composition were identified (Study-II). The five groups varied in risks of repeated hospitalizations due to substance use and psychiatric disorders (Study-III). Older persons experienced their ageing and alcohol use having a dynamic interplay (Study-IV). They needed to constantly negotiate with their environment to maintain a positive ageing trajectory. They perceived moderate alcohol use fosters healthy ageing, but over time, experienced their alcohol use as unsustainable and a threat to their pursuit of healthy ageing. Stigma and ambivalence delayed treatment seeking (Study-IV). They accessed treatment programs which re­spected their preferences and autonomy, engaged them in goal setting and strengthened their agency. After reducing their alcohol use, positive changes in their biopsychosocial functioning encouraged them to continue their recovery journey even in the presence of setbacks (Study-IV).

Conclusion: Most older persons who access municipal addiction services are hospitalized repeatedly. Many older persons with alcohol problems live with medical and psychiatric comorbidities suggesting multiple care needs from health and social care services. Incor­porating older persons’ desire for healthy ageing into alcohol treatment plan can facilitate treatment engagement and recovery. Many older persons aim to moderate their alcohol consumption. Clinicians can deliver person-centered care for older persons, by consider­ing their heterogeneity in treatment goals, biopsychosocial functioning, and available re­sources. A multidimensional identification of alcohol use profiles could improve treatment by establishing the variation in alcohol problems among older treatment seekers. Older persons stay engaged in alcohol treatment programs which value their experiences and expertise, incorporate their personal treatment and life goals, respect their autonomy and agency, and involve them as active participants. Sensitizing service providers on old age substance use problems could provide multiple points of contact for screening of older persons and earlier referral to treatment. A streamlined data sharing within and between health and social care services fosters timely and equitable care and facilitates an inte­grated and person-centered care across the continuum. 

Place, publisher, year, edition, pages
Umeå: Umeå University , 2023. , p. 98
Series
Studier i socialt arbete vid Umeå universitet : avhandlings- och skriftserie, ISSN 0283-300X ; 100
Keywords [en]
older adults, substance use disorder, alcohol use disorder, comorbidity, recovery, alcohol treatment, aging, healthy aging, integrated care, person-centered care, biopsychosocial model, register-based, longitudinal, latent class
National Category
Substance Abuse Gerontology, specialising in Medical and Health Sciences Social Work
Research subject
medical behavioral science; health services research; health services research; Psychiatry
Identifiers
URN: urn:nbn:se:umu:diva-205174ISBN: 978-91-8070-010-8 (electronic)ISBN: 978-91-8070-009-2 (print)OAI: oai:DiVA.org:umu-205174DiVA, id: diva2:1739497
Public defence
2023-03-24, Hörsal UB.A.220 (Lindellhallen 2), Umeå, 13:00 (English)
Opponent
Supervisors
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2016-07213The Royal Swedish Academy of Sciences, SO2021-0027The Kempe FoundationsAvailable from: 2023-03-03 Created: 2023-02-25 Last updated: 2023-02-27Bibliographically approved
List of papers
1. Hospital admission rate, cumulative hospitalized days, and time to admission among older persons with substance use and psychiatric conditions
Open this publication in new window or tab >>Hospital admission rate, cumulative hospitalized days, and time to admission among older persons with substance use and psychiatric conditions
2022 (English)In: Frontiers in Psychiatry, E-ISSN 1664-0640, Vol. 13, article id 882542Article in journal (Refereed) Published
Abstract [en]

Background: Substance use among older persons occurs with medical and psychiatric comorbidities. This study examined the associations of substance use disorder (SUD), psychiatric, and dual diagnoses with 12-month cumulative hospitalized days, hospital admission rate and number of days to first hospitalization.

Methods: The cohort of 3,624 individuals (28.2% women) aged 50 years or older was assessed for substance use severity in 65 Swedish municipalities during March 2003–May 2017. Addiction Severity Index data were linked to hospital discharge records and crime statistics. The outcomes were (a) 12-month cumulative hospitalized days; (b) Hospital admission rate, and (c) days to first hospitalization. Generalized linear regression techniques investigated associations between outcomes and SUD, psychiatric and dual diagnoses at admission.

Results: During 2003–2017, 73.5% of the participants were hospitalized. Twelve-month hospitalized days were positively associated with SUD (Incidence rate ratio (IRR) = 1.41, 95%CI: 1.26–1.58), dual diagnosis (IRR = 2.03, 95%CI: 1.74–2.36), and psychiatric diagnoses (IRR = 2.51, 95%CI: 2.09–3.01). Hospital admission rate was positively associated with SUD (IRR = 4.67, 95%CI: 4.28–5.08), dual diagnosis (IRR = 1.83, 95%CI: 1.64–2.04), and psychiatric diagnoses (IRR = 1.73, 95%CI: 1.55–1.92). Days to first hospitalization were negatively associated with SUD (IRR = 0.52, 95%CI: 0.47–0.58), dual diagnosis (IRR = 0.57, 95%CI: 0.50–0.65), and psychiatric diagnoses (IRR = 0.83, 95%CI: 0.73–0.93). The marginal effects of SUD and/or mental disorders increased with age for all outcomes, except for days to first hospitalization.

Conclusion: Three of four older persons assessed for substance use severity were later hospitalized. Substance use disorders, dual diagnoses and other mental disorders were the primary reasons for hospitalization and were associated with longer stays, earlier hospitalization, and repeated admissions. Sensitizing service providers to old age substance use and sharing data across the care continuum could provide multiple points of contact to reduce the risk of hospitalizations among older persons with problematic substance use.

Place, publisher, year, edition, pages
Frontiers Media S.A., 2022
Keywords
aged, repeated hospitalizations, length of stay (D007902), older adult, dual diagnosis, substance use disorder, mental health disorders, comorbidities
National Category
Psychiatry Social Work Geriatrics
Research subject
Social Medicine
Identifiers
urn:nbn:se:umu:diva-194017 (URN)10.3389/fpsyt.2022.882542 (DOI)000876149900001 ()35530023 (PubMedID)2-s2.0-85129652326 (Scopus ID)
Projects
STANCE
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2016-07213The Royal Swedish Academy of SciencesThe Kempe Foundations
Available from: 2022-04-22 Created: 2022-04-22 Last updated: 2024-01-17Bibliographically approved
2. A Multidimensional Latent Class Analysis of Harmful Alcohol Use Among Older Adults: Subtypes Within the Swedish Addiction Severity Index Registry
Open this publication in new window or tab >>A Multidimensional Latent Class Analysis of Harmful Alcohol Use Among Older Adults: Subtypes Within the Swedish Addiction Severity Index Registry
2020 (English)In: Journal of addiction medicine, ISSN 1932-0620, E-ISSN 1935-3227, Vol. 14, no 4, p. e89-e99Article in journal (Refereed) Published
Abstract [en]

Objectives: The present study aimed to identify multidimensional typologies of harmful alcohol use based on the Swedish Addiction Severity Index (ASI) assessment data on individuals aged 50 years and above.

Methods: Latent class analysis examined 11 indicators from ASI data on 1747 individuals (men = 1255, women = 492) who reported they were troubled by alcohol problem at least one day in the past 30 days before their assessment. The discriminative validity of the classes was assessed by comparing other measures of individual characteristics and problem severity of other ASI dimensions.

Results: Five subtypes of harmful alcohol use were identified. Two classes with alcohol problems varying in psychosocial functioning, age composition and ages of onset of both regular and heavy drinking. Two with psychiatric comorbidity but varying in violence, criminality, gender composition and ages of onset of regular and heavy drinking. One with high prevalence of concurrent use of other substances, psychiatric, legal, and employment problems.

Conclusions: The analysis identified, in a national sample, heterogeneous risk groups of older adults with harmful alcohol use. These findings suggest a need for healthcare providers to assess older adults not only for their substance use but also for associated problems and needs. Given these findings, the Addiction Severity Index is a valuable assessment tool for older adults with harmful alcohol use.

Place, publisher, year, edition, pages
Wolters Kluwer, 2020
Keywords
addiction severity index, harmful alcohol use, older adults, register-based study, subtypes
National Category
Substance Abuse Psychiatry Social Work Public Health, Global Health, Social Medicine and Epidemiology
Research subject
medical behavioral science
Identifiers
urn:nbn:se:umu:diva-168621 (URN)10.1097/ADM.0000000000000636 (DOI)000619442100017 ()32097236 (PubMedID)2-s2.0-85089202504 (Scopus ID)
Projects
Substance Use Disorder Among Older Adults: typologies, pathways and health outcomesSTANCE
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2016-07213
Note

Acknowledgement: The first author (WBJ) was also awarded grant from the Kempe Foundation to cover tuition fees for methodological courses relevant to this study.

Available from: 2020-03-03 Created: 2020-03-03 Last updated: 2023-09-05Bibliographically approved
3. Recurrent risk of hospitalization among older persons with problematic alcohol use: a multiple failure‐time analysis with a discontinuous risk model
Open this publication in new window or tab >>Recurrent risk of hospitalization among older persons with problematic alcohol use: a multiple failure‐time analysis with a discontinuous risk model
2022 (English)In: Addiction, ISSN 0965-2140, E-ISSN 1360-0443, Vol. 117, no 9, p. 2415-2430Article in journal (Refereed) Published
Abstract [en]

Background and Aims: Older persons with problematic alcohol use vary in psychosocial functioning, age of onset for problem drinking and use of other drugs. The study measured the differential risks of all-cause, alcohol, polydrug and psychiatric-related repeated hospitalizations among older persons with problematic alcohol use.

Design: A linked register-based cohort study with discontinuous multiple-failure (time-to-repeated-event) data. Hospitalization and mortality were considered as failure.

Setting: Sweden, March 2003-November 2017, using data from the Addiction Severity Index (ASI) register linked to National Inpatient Register and the Swedish Cause of Death Register.

Participants: 50 years and older (n= 1741; 28% women), with one or more alcohol problem days in the 30 days before an ASI assessment.

Measurements: Five mutually exclusive latent classes of problematic alcohol use, identified with eleven ASI items, were the independent variables: “Late Onset with Fewer Consequence (LO:FC; reference group)”; “Early Onset/Prevalent Multi-Dimensional problems (EO:MD)”; “Late Onset with co-occurring Anxiety and Depression (LO:AD)”; “Early Onset with co-occurring Psychiatric Problems (EO:PP)”; and “Early Onset with major Alcohol Problem (EO:AP)”. Covariates included sociodemographic characteristics, previous hospitalization and Elixhauser comorbidity index. Outcome measurements included recurrent hospitalization, and/or mortality due to: (a) all-cause, (b) alcohol-related disorders and diseases (c) polydrug use (d) other psychiatric disorders.

Findings: During the study period, 73.2% were hospitalized at least once, 57.3% were alcohol-related, 8.5% polydrug use and 18.5% psychiatric-related diagnoses. Compared with LO:FC, EO:PP had higher risk for all-cause (adjusted hazard ratio [aHR]= 1.27, 95% confidence interval [CI]= 1.02—1.59) and alcohol-related (aHR= 1.34, 95% CI= 1.02—1.75) hospitalizations. Adjusted risks for polydrug-related hospitalization were 2.55, 95%CI= 1.04—6.27 for EO:MD and 2.62, 95%CI= 1.07—6.40 for EO:PP. Adjusted risk for psychiatric-related hospitalization was higher for LO:AD (aHR= 1.78, 95%CI= 1.16—2.73 and EO:PP (aHR= 2.03, 95%CI= 1.22—3.38).

Conclusions: Older addiction service users in Sweden have varying risks of hospitalization due to alcohol use, polydrug use and psychiatric disorders. Older persons with problematic alcohol use who have multiple needs and are assessed in social services may benefit from earlier interventions with an integrated focus on substance use and mental health.

Place, publisher, year, edition, pages
John Wiley & Sons, 2022
Keywords
hospital readmission, substance use disorder, mental health disorder, longitudinal study, dual diagnoses, aged, addiction care, addiction services, at-risk drinking, at-risk alcohol consumption
National Category
Psychiatry Social Work
Research subject
Psychiatry; Social Medicine
Identifiers
urn:nbn:se:umu:diva-194237 (URN)10.1111/add.15907 (DOI)000792509600001 ()35470927 (PubMedID)2-s2.0-85129627252 (Scopus ID)
Projects
Substance Use Disorder Among Older Adults: typologies, pathways and health outcomesSTANCE
Funder
The Royal Swedish Academy of Sciences, SO2021-0027Forte, Swedish Research Council for Health, Working Life and Welfare, 2016-07213Swedish Research Council, 2013‐08755
Available from: 2022-04-28 Created: 2022-04-28 Last updated: 2023-02-27Bibliographically approved
4. "Ageing with an alcohol problem is not what I envision": reclaiming agency in shaping personal ageing trajectory and recovery from alcohol problems
Open this publication in new window or tab >>"Ageing with an alcohol problem is not what I envision": reclaiming agency in shaping personal ageing trajectory and recovery from alcohol problems
2023 (English)In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 23, article id 866Article in journal (Refereed) Published
Abstract [en]

Background: Eliciting and understanding older persons’ descriptions of their resources for healthy ageing and the interaction of these resources with alcohol use and alcohol problems can facilitate health promotion. It can also inform clinicians when identifying areas of recovery capital that present risks and strength for older people seeking alcohol treatment. The objective of this study was to illuminate the experiences and perspectives of older persons on ageing, alcohol use, treatment, and recovery from alcohol problems, as well as their understanding of healthy ageing.

Methods: Eight men and two women, aged 61 to 73 years, with moderate drinking as a treatment goal and treated at an outpatient alcohol clinic in Sweden, participated in semi-structured audio-recorded virtual interviews. A qualitative content analysis examined the transcribed interviews.

Results: Three themes were identified: “Tipping the balance”, “Staying behind a veil” and “Lifting the vail”. First, participants understood healthy ageing as a personal and multidimensional process that involved actively expanding, maintaining or adjusting to the resources needed to lead an active and meaningful life while preserving autonomy, dignity and independence for as long as possible. Second, most participants viewed moderate alcohol use as a contributor to healthy ageing. They sought treatment when their drinking became unsustainable and an immediate threat to their healthy ageing resources. Stigma, ambivalence and a lack of treatment options, however, contributed to delayed treatment. Third, the participants responded to treatment approaches that elicited their concern, incorporated their expertise and treatment and life goals, appreciated their autonomy and agency, and considered them partners in goal setting and decision making. Reduced drinking helped participants regain their agency and improved their healthy ageing capital which in turn catalyzed continuing recovery.

Conclusions: Older persons in non-abstinent recovery perceive healthy ageing and alcohol recovery as personal and interacting multidimensional processes involving their agency to improve biopsychosocial functioning. Treatment approaches that recognize older persons’ desire for healthy ageing, incorporate their treatment goals and respect their autonomy are likely to be acceptable and effective.

Place, publisher, year, edition, pages
BioMed Central (BMC), 2023
Keywords
Alcohol use disorder, Healthy aging, Aged, Quality of life, Recovery, Stigma, Alcohol treatment, Person-centered care, Alcohol
National Category
Psychiatry Geriatrics Substance Abuse Social Work Gerontology, specialising in Medical and Health Sciences Psychology
Research subject
medical behavioral science
Identifiers
urn:nbn:se:umu:diva-205173 (URN)10.1186/s12877-023-04573-y (DOI)2-s2.0-85179992364 (Scopus ID)
Projects
Substance Use Disorder Among Older Adults: typologies, pathways and health outcomes
Funder
The Kempe Foundations, 2022-04-26The Royal Swedish Academy of Sciences, SO2021-0027Forte, Swedish Research Council for Health, Working Life and Welfare, 2016-07213
Available from: 2023-02-25 Created: 2023-02-25 Last updated: 2023-12-28Bibliographically approved

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Jemberie, Wossenseged Birhane

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