Assessment of alcohol and psychotropic drug use among old-age psychiatric patients in Norway: Experiences of health professionals.

BACKGROUND: Increased awareness among health professionals regarding older people's alcohol and prescribed psychotropic drug use may be beneficial for reducing their unhealthy consumption among elderly. AIM: This study explores how health professionals experienced their participation in a study in which they collected data on alcohol and psychotropic drug use among patients treated in old-age psychiatry departments and, subsequently, how they experienced their work day after the study ended.
METHOD: Focus-group and individual interviews with 15 professionals in specialist psychiatric hospitals were performed in 2016. The data were analysed using content analysis.
RESULTS: Two themes emerged from the data: the informants' "experiences with participation" and "consequences of participation". These themes described how the informants had experienced their participation in the study and whether these experiences subsequently affected their work routines. The first theme included two subthemes: "approaching the topic" covered the challenges and "applying assessment scales" described the participants' opinions about the scales. Two subthemes were included in the second theme: "increasing knowledge", which covered their reflections on new knowledge; and "influencing work routines", which described their new approach to the topic.
CONCLUSION: Study participation positively affected the informants' work routines regarding alcohol and psychotropic drug use. The results of this study may contribute to a better understanding, development, and organization of services for people with increased substance use and thus may more holistically promote the health of older people.

In recent decades, the consumption of alcohol and psychotropic drugs has increased among people over 65 years of age in Europe as well as in Norway (Bye & Østhus, 2012; Midtflå, 2007; Støver, Bratberg, Nordfjærn, & Krokstad, 2012; WHO, 2013). A Norwegian study by Støver and colleagues (2012) further reported that the use of psychotropic drugs increased with increasing age. This trend may represent a major challenge to the health of older populations, especially if the consumption of alcohol and psychotropic drugs, alone or in combination, is high. First, the intake of alcohol and psychotropic drugs can interact with the ageing process itself and lead to poorer health outcomes and impaired function in activities of daily living (Blow & Barry, 2012; Rao, Crome, Crome, Ramakrishnan, & Iliffe, 2015). One explanation for this association could be that older people have a lower capacity to manage the same level of alcohol consumption as they could earlier in life, leading to a high burden from injuries, such as falls (Grundstrøm, Guse, & Layde, 2012). Second, according to the World Health Association (WHO), alcohol negatively affects at least 60 diseases, both physical and mental (WHO, 2004); as older people often have one of more chronic diseases, it is likely that many of them will suffer from one of these 60 diseases (WHO, 2004; see also Caputo et al., 2012; Merrick et al., 2008; Satre, Sterling, Mackin, & Weisner, 2011; Schuster, Hoertel, Le Strat, Manetti, & Limosin, 2013). Furthermore, physical health problems and long-term prescription of psychotropic drugs are important factors in the development of substance dependence in older people. The use, or elevated use, of substances can be non-specific, and the role of substance use in the treatment of physical conditions is frequently overlooked (Mules et al., 2012; Rao et al., 2015).

Similar to the results of a recent Norwegian study (Johannessen, Engedal, & Helvik, 2016), an Australian study showed that elevated alcohol and psychotropic drug use among older people seeking treatment is frequent (Draper et al., 2015). Other studies have noted that departments of old-age psychiatry in specialist healthcare are an important setting for identifying elevated use of these substances (Sandvik, 2014) and that benzodiazepines are commonly used when older adults are admitted to these departments. However, the corresponding patient referrals do not necessarily include information about patients’ substance use (Høiseth, Kristiansen, Kvande, Lorentzen, & Refsum, 2013). Including more accurate information on referrals may increase the quality of treatment, as late-onset elevated substance use is more likely to have a better treatment prognosis than early-onset misuse (Moy, Crome, Crome, & Fisher, 2011; O’Connell, Chin, Cunningham, & Lawlor, 2003; Rao et al., 2015).

Recent studies have shown that health professionals seldom assess alcohol and psychotropic drug use when they provide services for old people (Jensen, Lukow, & Heck, 2012; Johannessen et al., 2014; Johannessen, Helvik, Engedal, & Sørlie, 2015; Mules et al., 2012; Sandvik, 2014), and knowledge of alcohol and substance use in older adults is thus limited (Rosen, Engel, Hunsaker, Engel, & Reynolds, 2013). In Norway, the guidelines for the diagnosis, treatment and follow-up of individuals with a substance-use disorder and co-morbid mental illness do not specifically focus on older people (ROP-Guidelines, 2012).

A study of personnel in Danish hospitals (Hellum, Bjerregård, & Nielsen, 2016) showed that the most important barriers to talking with patients about alcohol use among professional caregivers were their lack of experience in the matter, lack of knowledge, and lack of self-confidence. This Danish study, as well as a previous Norwegian study, reported that the health personnel who participated in studies about alcohol consumption and use of psychotropic drugs wanted to overcome some of these barriers (Hellum et al., 2016; Johannessen et al., 2014). However, there is a lack of knowledge of how health professionals experience their participation in studies that assess alcohol and psychotropic drug use among older patients and whether this participation affects their daily work routine, i.e., whether they have a greater knowledge of and focus on alcohol and psychotropic use after participation.

Given this background with the reviewed literature, we believe that increasing health professionals’ attention to the use of alcohol and psychotropic drugs may be effective for reducing the unhealthy consumption of these substances among older people because these professionals will more frequently discuss these substances and their use with old patients. Thus, we at first conducted a study (Johannessen et al., 2017) in which health professionals in departments of old-age psychiatry collected data to compare information given in the referral note with that reported by the patients about the use of alcohol and psychotropic drugs. The present study is a follow-up study with the aim to explore how health professionals experienced their participation in a study in which they collected data on alcohol and psychotropic drug use among patients treated in old-age psychiatry departments and, subsequently, how they experienced their work day after the study ended.

Methods

The framework

The study (Johannessen et al., 2017) in which health professionals in departments of old-age psychiatry collected data on alcohol and psychotropic drug use used a standardized protocol that included scales to assess alcohol use (the Alcohol Use Disorders Identification Test – AUDIT: Babor, De La Fuente, Saunders, & Grant, 1989) and psychotropic drug use (the Drug Use Disorders Identification Test – DUDIT: Berman, Bergman, Palmstierna, & Schlyter, 2005). The participating health professionals were trained in how to conduct interviews, perform testing, and use assessment scales. Most of the scales in the study were well known by the health professionals, and for that reason the supervision focused mainly on the assessing scales AUDIT and DUDIT by telephone. The purpose of the previous study was to examine whether patients’ self-reported use of alcohol and prescribed psychotropic drugs corresponded with the information provided by the physicians referring these patients to the departments of old-age psychiatry (Johannessen et al., 2017).

The definition of elevated use

Different terms have been used to describe the use and misuse of alcohol and psychotropic drugs, including dependency, harmful use, risky use, and elevated use (Hallberg, Högberg, & Andreasson, 2009). Throughout the present study, we use the term “elevated use”, and for alcohol intake, we define elevated use as more than one alcohol unit a day for patients of both genders aged 65 years and above. This definition is in accordance with that of The American Geriatric Society (2003).

Data collection and participants

Data were collected using individual and focus-groups interviews (Berg & Lune, 2012) performed with health professionals who were involved in assessing the use of alcohol and psychotropic drugs among patients referred to departments of old-age psychiatry, as described above. The informants were included purposively to ensure variation in the sample. A total of 15 women, aged 42 to 63 years, were interviewed in 2016, within a year after they had completed data collection for the previous study. The informants had worked in old-age psychiatry for five to 27 years. Ten were nurses, two were occupational therapists, two were physiatrists, and one was a social worker. One of the informants had previous experience working with patients who misused alcohol, but not with older people in particular. They represented ten departments of old-age psychiatry from large regions of Norway. The informants were contacted by telephone and asked to participate.

We performed two group interviews with nine of the included participants who attended an old-age psychiatric congress: one group consisted of five informants, and one group had four informants. Those participants who worked together were mainly separated into different groups. The two focus-group interviews were conducted in a neutral meeting room in a hotel with two moderators (AJ and A-SH) who drew out information regarding topics of importance to the aim of the study. The interviews lasted 46 to 69 minutes (Berg & Lune, 2012). The remaining six participants were interviewed individually, given the long travel distances between the researcher and the participants. The individual interviews were conducted by AJ over the telephone at a time convenient for the participants, and lasted 12 to 32 minutes (Berg & Lune, 2012).

A professional typist transcribed the recorded interviews verbatim within two weeks of each interview. AJ performed quality control checks of all the transcripts by listening to the tapes while reading the interview transcripts (Kvale & Brinkmann, 2009).

An interview guide based on thematic questions was applied for the interviews. This guide contained three questions about the informants’ experiences assessing alcohol and psychotropic drug use among patients referred to an old-age psychiatry department and about whether participation had subsequently affected their daily work (Table 1). Based on the participants’ responses and reflections, the aspects and ideas they raised led to further questions. These questions were asked and documented in field notes, and they were asked again in the following interviews to enrich, elaborate and expand on the information given (Lincoln & Guba, 1990).

Table 1.

Overview of the main questions asked in the interview.

How has your participation in this project been in terms of assessing alcohol and psychotropic drug use among patients in your department?

Has participation in this project resulted in any changes in the routines used to address alcohol and psychotropic use in your department?

How can efforts to address alcohol and psychotropic drug use be sustained in your department?

Analysis

The transcribed data were analysed using manifest qualitative content analysis (Graneheim & Lundman, 2004). First, the transcribed text was read carefully several times to establish an overall impression of the data. As no substantial differences were identified between the individual interview and focus-group data regarding the content or depth, the analysis was performed on the text as a whole. “Meaning units”, i.e., words and sentences expressing a central meaning, were then identified and later systematically condensed without changing the original meaning. In the second stage, the condensed units were labelled with a code that described their content. In the third and final stage, categories and subcategories were created. These themes consisted of groups of codes according to the categories identified in the interviews. Special attention was paid to establishing clear differences between and similarities within codes and categories (Graneheim & Lundman, 2004). AJ and A-SH were primarily responsible for the analysis, but the process was continuously discussed with the co-authors.

Ethics

The present study followed the ethical principles outlined in the Declaration of Helsinki (WMA, 2013). The study was presented to the Regional Committee for Ethics in Medical Research, Southern Norway, and was subsequently approved. Consent from the informants was obtained after they had received verbal and written information about the study and before they participated in the interviews.

Results

Two themes related to the informants’ opinions and experiences emerged: “experiences with participation” and “consequences of participation” (Table 2). Each theme included two subthemes, which presented different aspects of the informants’ experiences.

Table 2.

The themes and subthemes that emerged from the structural analysis.

Themes	Subthemes
Experiences with participation	Approaching the topic
	Applying assessment scales
Consequences of participation	Increasing knowledge
	Influencing work routines

Experiences with participation

Approaching the topic

The informants stated that it was challenging to discuss elevated alcohol and psychotropic drug use with patients not only because alcohol was still a slightly private and taboo topic but also because the psychotropic drugs had been legally prescribed by physicians, mainly general practitioners (GPs). They stated that older people had little knowledge of the health risks associated with any use and elevated use of alcohol and psychotropic drugs. Older people could also be slightly confused about who to believe or trust regarding prescribed psychotropic drugs. Moreover, the informants also discussed and expressed that it was time consuming and difficult to assess elevated alcohol and psychotropic drug use because of all the other work tasks they were responsible for in daily clinical practice. In addition, some reported that they occasionally knew that the reported alcohol use among some patients did not match their actual consumption given their knowledge from living in rural areas. This awareness presented challenging situations that were difficult to address. One informant expressed the following:Another informant said:Moreover, the informants expressed that because the patients were old and sometimes had cognitive impairments, they had to be careful with how they phrased the questions, which could be a hindrance. Others again expressed that they had previously had questions about alcohol use in their routine assessments but that they did not ask follow-up questions. Some informants perceived that it was crucial to have established a relationship with patients before asking about alcohol and psychotropic drug use. In their conversations with patients with elevated use, the importance of focusing on the benefits that patients would gain from reducing their alcohol and/or prescribed psychotropic drug use was also discussed in the groups. One informant stated that they tried to focus on this topic in patient conversations in the following manner:Moreover, she (the same informant) stated that these types of conversations could motivate patients to reduce their unhealthy alcohol and/or psychotropic drug use.

It took me some time to feel comfortable asking about elevated alcohol and psychotropic drug use. I had to work on that, and it was time consuming too, but it was actually interesting and quite all right to get on with [conversations] while focusing on the topic. (Individual interview number four)

You got used to asking patients about these things, and what we were most excited about was that it was a little bit like…perhaps a little bit of a taboo to talk about such things. It was also the patients’ reactions that I was excited about; but all in all, it was not a problem, and the patients were relatively calm talking about their alcohol and psychotropic drug use. (Individual interview number three)

If you fall and break your leg, how would you be then? Is it not better to walk safely to the shop and perhaps be able to drive your car? (Focus interview number two)

Applying assessment scales

As part of their daily work tasks, the informants were accustomed to using different assessment scales for cognitive impairment, psychiatric disorders, and activities of daily living. Focusing on alcohol and medications was also a component of their work, but the AUDIT and DUDIT were new to most of them. Their opinions about these two scales differed, but they still found them useful in one way or another, as expressed by one informant:The informants found that the AUDIT was difficult to use. The questions about units were challenging because patients did not know what a unit of alcohol was. The questions were designed in a way that made it difficult to ask questions of people without known elevated alcohol use. One informant said:The DUDIT scale was even more difficult to apply because the questions were not suitable for this group of patients, who used prescribed psychotropic drugs. The departments of old-age psychiatry in this study occasionally had in-patients with illegal drug use, and in these cases, the DUDIT was considered useful, as stated by one of the informants:

Perhaps it is easier to ask about alcohol and psychotropic drug use when you use these scales, because then, in a way, you must go through the questions as they are. You can then tell the patient…“Here, I have something that I have to survey, can you please answer these questions I have here?” (Focus interview number two)

I think that the AUDIT scale is slightly difficult to use; the questions are too direct. I believe that…because you cannot just ask the question right out of the questionnaire. You have to think to yourself and try to include the questions throughout the conversation with the patients, perhaps. Yes, I do believe that the tool is slightly difficult to use, too direct. (Individual interview number six)

We have always had a focus on medication use in our department. Therefore, in that way, I do not think that the DUDIT scale gave us more information than we already had without that particular questionnaire; however, if we were to get patients with illegal drug use, then it could be useful. (Individual interview number five)

Consequences of participation

Increasing knowledge

After participating in the data collection for the previous project, the informants expressed in the group discussions and in the interviews that they had become more aware of the importance of the topic and that they wanted to maintain a special focus on elevated alcohol and psychotropic drug use in the treatment of patients referred to old-age psychiatric departments. The project also contributed to identifying better ways of talking about the topic with older people. The informants also reported that they had learned a lot about elevated alcohol and psychotropic drug use through their participation in the project.In addition, another informant stated the following in the group discussion:Furthermore, the informants reported in the interviews and the group discussions that simply asking about alcohol and psychotropic drug use and elevated use was beneficial for the treatment of older people in the department because they found that the patients began reflecting on their own use. They also obtained knowledge about patients who had elevated use of these substances that helped them initiate treatment. Furthermore, some of the patients’ honest answers about elevated alcohol or psychotropic drug use surprised them. The informants expressed in the discussions and in the interviews that knowledge about the difficulties associated with increased alcohol use in the general older population was important as the associated health demands could present serious challenges in the future with the growing proportion of older adults. One informant expressed this sentiment in the following way:

I think it has been exciting, educational, and quite fun to participate. (Individual interview number six)

We always have these questions about alcohol and psychotropic drug use in the first meeting with the patient and family carer at admission to the hospital ward. I think it is better to talk about the use of these substances in a conversation, rather than using the assessment scales, but I have perhaps been more conscious about focusing on alcohol and psychotropic drug use in these conversations after participating in the project. (Focus interview number one)

Knowledge of the rising alcohol use in the general older population must encourage us too so that we are enthusiastic about finding scales that are beneficial for assessing elevated alcohol use. (Focus interview number two)

Influencing work routines

The informants stated in the discussions and in the interviews that the project had influenced their approach to working in the departments in one way or another. They found it easier to talk about alcohol and psychotropic drug use when treating patients. Project participation also led to discussions among health personnel about how to discuss these two topics with patients in their department. Moreover, the scales (AUDIT and DUDIT) made it easier to ask more questions about the topic in detail, i.e., to expand on general questions. In some ways, they were more focused on possible cases of elevated alcohol and psychotropic drug use in their department. One informant stated:The routines for assessing elevated alcohol and psychotropic drug use had changed in quite a few departments, but it was difficult to focus on the topic if there was not a broad agreement in the department to continue to do so. Nonetheless, it was challenging to continue or keep up with the assessments of all the patients admitted to the units. Informants used the scales when they perceived it could be beneficial.It was discussed and expressed that the project had led to a broader understanding of the topic, that the topic had greater focus in the collaboration within the department and with health personnel in the municipality and that it was considered as an important task. One of them expressed:

At our hospital, we are used to asking patients to participate in research. We have routines for that, but still, it has been fun to participate in this research, and it became more fun after a while. We learned more techniques for how to ask patients about alcohol and prescribed drug use, and we transferred that knowledge to hospital routines. (Focus interview number two)

We do not assess for alcohol and psychotropic drugs systematically, but when we feel that there might be elevated alcohol and/or medication use based on the introductory questions about elevated alcohol and medication use, then we have started using the scales. (Individual interview number five)

Even though there were just a few that I assessed, it has definitely done something to my practice in the department. Now, I have a great interest in collaborating with the municipality team and the GPs on this topic. The project increased my competence, understanding, and attitudes towards elevated alcohol and psychotropic drug use. (Focus interview number one)

Discussion

The main results of our study showed that study participation had a positive influence on the informants, as their knowledge of elevated use of alcohol and psychotropic drugs increased and their work routines regarding alcohol and psychotropic drug use changed. The results are discussed in order of the presented subthemes (see Table 2).

First, our study showed that “approaching the topic” was a challenging task because alcohol use was viewed as a private matter and taboo to discuss. This finding is in line with previous research, which has found that both health personnel in Norwegian municipalities and older citizens tended to perceive alcohol use as a private matter, a part of the culture and not a subject that one talks about with healthcare personnel (Johannessen et al., 2014; Johannessen, Helvik, Engedal, & Sørlie, 2015; Johannessen, Helvik, Engedal, Ulstein, & Sørlie, 2015). Another study reported that GPs rarely discussed alcohol consumption with their older patients unless the consumption of alcohol had an obvious and direct influence on the patients’ current health (Mules et al., 2012). This approach should be questioned, because of alcohol’s negative influence (WHO, 2004) since a moderate consumption among older people may have a negative influence on many of the diseases that can occur in an older population (WHO, 2013).

Moreover, although our study showed that it was difficult to discuss alcohol and psychotropic drug use, it was interesting that the informants had found it beneficial to participate in collecting data for the previous project. The screening was the first step to creating an interest in the topic, and later studies can use other approaches to start such a process towards the topic. We therefore suggest that health personnel should be provided with adequate education and should be encouraged to focus more on the use of alcohol and psychotropic drugs when talking with their patients than they currently do. As pointed out earlier, studies indicate a lack of emphasis on assessing the elevated use of alcohol and psychotropic drugs when treating older people (Jensen et al., 2012; Johannessen et al., 2014; Johannessen, Helvik, Engedal, Ulstein, & Sørlie, 2015; Mules et al., 2012; Sandvik, 2014).

Our study also showed that in participants’ conversations with patients about the use and elevated use of these substances, it was important to focus on the health benefits provided by reducing alcohol and/or prescribed psychotropic drug use. The participants perceived that older patients had little knowledge of the health risks associated with elevated alcohol and psychotropic drug use. Another study by Johannessen and colleagues (2014) similarly concluded that older people are not always aware of the health risks linked to elevated alcohol and psychotropic drug use. Information about these health risks is important and should be disseminated to the general population of older adults because the use of these substances has increased among older people and is dangerous to their health (Bye & Østhus, 2012; Midtflå, 2007; Simoni-Wastila & Huiwen, 2006; Støver et al., 2012; WHO, 2004).

In terms of “applying assessment scales”, the participants were trained to use different assessment scales, but the AUDIT and DUDIT were new to most of the health professionals. Although opinions about these scales varied, the participants still found them useful and found that the scales made it easier to ask patients about their alcohol and psychotropic drug use. The AUDIT scale was challenging because the questions included the term “alcohol unit”, which the patients were not familiar with and did not understand intuitively. The DUDIT scale was especially difficult to use because the questions were not largely applicable to a group of patients who did not use illicit drugs. The participants also mentioned that the DUDIT scale did not contribute to wider information about drugs. However, the DUDIT is still recommended for conducting assessments of problematic prescribed drug use (Voluse et al., 2012). An inventory with a better performance than the DUDIT does not exist to date.

The informants further expressed that the study contributed to “increasing knowledge” and that they had learned a considerable amount about elevated alcohol and psychotropic drug use by participating in the project since they were not used to focusing on or screening for such use. This increased knowledge resulted in a greater awareness of and specific attention being paid to elevated alcohol and psychotropic drug use when treating patients. Overall, the project helped them identify better ways of discussing these topics, but it should also be pointed out that participants might be affected by social desirability in some instances. The informants also found that when asked about their use of substances, the patients began reflecting on their own use. Other studies have found that talking about a problem can result in a good therapeutic relationship or alliance, which in turn has a strong influence on treatment (Helseth, Lykke-Enger, Aamo, & Johnsen, 2005; Horvath, 2006).

The informants stated that the project “influenced work routines” in their departments. Specifically, they found it easier to talk about alcohol and psychotropic drug use, and additionally, the project led to discussions between health personnel about how to talk about elevated use of these substances. Moreover, the informants stated that they had learned better techniques for asking patients about their use of alcohol and prescribed psychotropic drugs. The project led to a broader focus on collaboration within the department and with health personnel in the municipality. It was evident that greater awareness of these topics was needed among health personnel providing services for older people, and this need has been reported in other studies as well (Duckert, Lossius, Ravndal, & Sandvik, 2008; Johannessen et al., 2014; Johannessen, Helvik, Engedal, & Sørlie, 2015; Sandvik, 2014).

Methodological considerations

The methodological choices in this study were motivated by the lack of previous studies on health professionals’ experiences with participation in a study on screening for the use of alcohol and psychotropic drugs, and on whether this participation had consequences for them and/or their daily work in old-age psychiatry departments.

Qualitative research methods are helpful for providing insight into phenomena and subjects that are not well known (Patton, 2002). The present study used a purposive sample of 15 health professionals who had been involved in examining whether patients’ self-reported elevated alcohol and prescribed psychotropic drug use corresponded with the information provided on their referral to a department of old-age psychiatry and the factors associated with this self-reported use. The participating professionals worked in different departments of old-age psychiatry in most regions of Norway; they were different ages, had different formal educational backgrounds, and had been working within this field for a few or for many years. In addition, one professional had experience working with patients who misused alcohol. We believe that this purposive sample helped validate the results, even if the sample was not purposive regarding gender (Patton, 2002). Also, using focus-group interviews that can contribute to exploring a topic in a wider manner than individual interviews is valuable to this topic (Kvaale & Brinkmann, 2009). We therefore strived to interview nine informants through focus-group discussions, while six informants were interviewed individually. The reason for not using only focus groups was primarily related to the long distances between some of the participating old-age psychiatry departments.

The authors found no clear differences between the data collected individually and in groups. To enhance the trustworthiness of the data, quotations were presented in the text. In addition, data were analysed and discussed between authors (Lincoln & Guba, 1990). Although our results cannot be generalized in a statistical sense, we argue that they can be transferred to other studies that assess alcohol and psychotropic drug use among patients referred to treatment in old-age psychiatry departments and other hospital departments or municipalities that care for older people. The results contribute to a better understanding, development and organization of services for people with elevated alcohol and psychotropic drug use and thereby promote health more holistically among older people.

Conclusion

This study showed that collecting data on the elevated use of alcohol and psychotropic drugs among old-age psychiatric patients had positive consequences for the informants and their work routines regarding alcohol and psychotropic drug use. The results may contribute to a better understanding, development and organization of services for people with elevated alcohol and psychotropic drug use, thereby promoting older people’s health through a more holistic approach.