Drugs, Ageing and Homelessness in Australia, presented at the Brain Injury Forum in April.

1. Drugs, ageing and homelessness in
Australia
Lucy Burns
National Drug and Alcohol Research Centre, University of New South
Wales, Sydney, Australia

2. Structure
• Evolution of the “baby-boomer” generation
• What this means for drug use and ageing in
Australia
• Housing issues
• What does this mean for policy and practice?

3. Alcohol use and problems are not new….
"...alcohol has existed longer than all human memory. It has
outlived generations, nations, epochs and ages. It is a part of
us.
For most of us it will continue to be the servant of man (and
woman) but will always be the master of some."
Our recent history
Morris Chaftez, Founding director, National Institute on Alcohol Abuse and Alcoholism.
OUR RECENT HISTORY

4. Birth of the baby boomers: 1946-64
• End of WW2 in 1945 Australia's ex-service men and women
returned to family life after 6 years of war conflict
• Came back with legacy: use of substances during
• Methamphetamine/ “uppers” to work, alcohol to wind down
• Nine months after return childbirth rates soared – more than 4 million born
1946-51: “baby boomer generation”
• Increased migration to Australia through negotiated agreements with other
governments and international organisations e.g a system of free or assisted
passages for United Kingdom residents

5. 1950s and 1960s: Teenagers and young adults
• Increased advances in science and technology
• Widespread testing and use of new synthetic pharmaceuticals
Big Pharma
• LSD testing , wider use of new drugs in psychiatry
experimentation with mind altering substances
Prescription drugs and painkillers readily available
• Cultural change: new and different music:
• rock and roll 1960s: bands, fashion
• Vietnam war: use of cannabis by troops and anti-war protestors

6. 1970s and 80s
• Between 1962-1972 population leapt by 3 million
• Drug experimentation continued: cannabis, LSD, heroin
• Vietnam war: anti-war protestors – rebellion against authority
• Labor came to power Gough Whitlam
• Free university education,
• Withdrawal of Australian troops from Vietnam
• Anti-discrimination laws for Aboriginal people
• Economic prosperity – good health care
• Increased longevity

7. Now and the future: Baby boomers 60+
Outcomes of problematic substance used different in older;
• Heighted sensitivity and reduced tolerance - same level of alcohol will have an
increased effect
• Physiological changes (smaller body volume/mass) = increased impact
• Leads to accelerated ageing: impaired stem cell regeneration and increased rates
of cell death
• When 40: biological age of 60
• Heightened use of medications that interact with alcohol, such as sedatives and
tranquillisers
• Poor mental and physical health
Women’s use converging with men’s: roles changed dramatically: moved into workforce –
leisure pursuits that were traditionally male dominated eg. Pubs; work social activities.
• Increased alcohol use
• Telescoping of outcomes – women become sicker quicker

8. What are the contemporary drug
patterns in older Australians

9. Daily alcohol use by age: 2007
0
5
10
15
20
25
Male Female
14-19
20-29
30-39
40-49
50-59
60+
More daily use
Less amount but more effect

10. Places of alcohol consumption
0
10
20
30
40
50
60
70
80
90
100
Home Friends
house
Licensed
premises
Restaurants Parties
14-19
20-29
30-39
40-49
50-59
60+
Increasing consumption at home
Increasing social isolation
Medication interaction/ Increased falls

11. Oxycodone prescriptions per thousand population, by 10 year age
group,2002 to 2008
0
50
100
150
200
250
300
350
400
2002/03 2003/04 2004/05 2005/06 2006/07 2007/08
numberper1,000population
20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80+
Most by older groups
Increasing over time
Interaction with other drugs/ alcohol

12. Overall number of adults aged 50 or older
with substance use disorder projected to
double by 2020
INCREASED SUBSTANCE USE = POOR
MENTAL HEALTH =INCREASED LIKELIHOOD
OF LOSS OF HOUSING

13. Linking substance use and homelessness in
older Australians

14. Who are homeless in Australia?
100,000 Australians homeless each night, sleeping in different
places
Most staying with friends/relatives
Half are under 24 and 10,000 are children
Increasing number of older people homeless (18% 2006
Census Counting the Homeless)
105,000
16,000 20,000
47,000
21,600
0
20,000
40,000
60,000
80,000
100,000
120,000
total rough
sleepers/improvised
dwellings (primary)
SAAP accommodation
(secondary)
staying with
friends/relatives
(secondary)
boarding houses
(secondary/tertiary)
Homeless Census 2006

15. Homelessness among older Australians
• Both structural and individual factors
(1) Individual : as noted poor physical / mental health;
(2) Also structural: Lack of acceptable / appropriate housing
• 2 groups : first time homeless at older age and chronic homeless
• First time homeless more likely to be women
• homeless in response to housing market/ policies; welfare safely net
• Long-term homeless more likely to be men
• poor physical/mental health – more likely to have mental health problems

16. Structural factors related to homelessness
“There is a great divide in Australia between those older people who
have secure and stable housing and those who live precariously in
private rental accommodation that is unsafe, expensive and
insecure”.
Private: Chronic undersupply and high cost
• Not age-appropriate: Unwillingness of many landlords to modify houses in
line with support needs, housing poorly suited to needs of older people.
Social: Limited amount of age appropriate social housing
Aged care: Residential care required for some BUT
• Mainstream services ill equipped
• Premature ageing – 54 to 50 and over
• Special care needs around ARB

17. Substance use and homelessness in older people
• Substance use patterns more risky
• exposed to elements and violence, poor nutrition, lack of opportunitIes
for hygiene
• Alcohol problems and traumatic brain injury highly prevalent
• History of homelessness + problematic alcohol use + traumatic brain
injury = accelerated cognitive deficits
• BUT do not necessarily meet the age criteria for access to services although
meet physical criteria
• THEREFORE Little or no targeted services available for this group

18. Brain injury among older
with substance use
problems

19. Study aims and methods
Aim: To describe the association between alcohol use and cognitive
processes in older homeless people and implications for services
Method:
• 50 Face-to-face client participant interviews
• Assess demographics, physical and mental health, social support,
cognitive performance, use of services
• Series of in-depth interviews with key experts in the areas of aged
care and homelessness to determine “gold standard” in care for
homeless people who are also alcohol dependent.

20. Methods
• Clients were recruited from Haymarket Centre for homeless people in inner
Sydney.
• Eligible if 45 years or older and homeless in past 6 months.
• Homelessness defined as:
• Primary homelessness: sleeping rough on the street or in a car or other
makeshift dwelling
• Secondary homelessness: staying in an accommodation service, hotel or
motel, or staying with family or friends because they had nowhere else
to live
• Tertiary homelessness: living in a boarding house/hostel or caravan
(insecure tenure)

21. Demographics
Centre
% male 70.4
Mean age 49.0
% Australian born 74.1
% identifying as Indigenous 14.8
% 10yrs or less education 74.0
Mean age first left school 15.0
Mean age first employed 16.0
% not in the labour market 74.1
% in receipt of government benefit 96.3
% ever married 51.8
% currently in serious, long-term relationship 7.4
% ever had children 66.7

22. Almost all participants had ever slept rough (94%) and stayed in crisis
accommodation (90%).
Cycling though different types
Ever homeless (%) Mean age (yrs)
Slept rough 94.0 31.2
Family/ friends 56.0 24.6
Stayed in motel 68.0 32.7
Crisis accommodation 90.0 33.8
Boarding/ rooming house 74.0 29.1
Caravan 36.0 26.4
Homelessness history

23. Cycles of homelessness
The earliest mean age of onset for the different homelessness states
• 25 years of age for staying with family and friends
• 26 years for staying in a caravan,
• 29 years for boarding/rooming house, and
• 31-34 years for sleeping rough, crisis accommodation and staying in a motel.
This pattern suggests participants experienced precarious housing situations
before first experiencing primary homelessness and accessing supported
accommodation services.

24. Condition % n Age at
diagnosis
Treated in last
month n
Treated in last
month %
Depression 53 56 29(1.6) 15 27
Liver disease 41 43 32(1.5) 14 9
Anxiety 39 41 26(1.6) 11 27
Psychosis 31 32 25(1.5) 9 28
Asthma 28 29 15(3.3) 7 24
Feet
problems
23 24 35(3.7) 3 13
Headaches 25 26 29(3.7) 2 8
Epilepsy 13 14 25(2.9) 6 43
Health issues
Uncontrolled chronic conditions; mental health, asthma and
epilepsy
BSI: 98th percentile for psychological distress

25. Alcohol variable %
Mean onset of regular drinking 17
Mean maximum drinks in one day 26
% ever abstinent 71
Mean number of quit attempts 19
% ever talked to health professional about drinking 68
% ever received helpful/effective treatment 50
% received treatment in past 12 months 28
% ever hospitalised overnight because of alcohol 50
Mean onset of first hospitalisation 30
% ever attended self-help group 42
% attended meeting in past 12 months 14
Alcohol use
95% lifetime alcohol dependence/ 75% currently alcohol
dependent

26. % Past month substance use
44
23 21
16
4
0
5
10
15
20
25
30
35
40
45
50

27. Alcohol Related Brian Injury
• Brain organ most sensitive to the toxic effects of chronic alcohol
consumption
• International literature: high exposure to brain injuries from falls and
assaults and injuries
• Wernickes encephalopathy: Direct result of alcohol use: thiamine deficiency
• Persistent learning and memory problems.
• Forgetful and quickly frustrated and have difficulty with walking and
coordination.
• Korsakoffs psychosis: problems “laying down” new information) that is the
most striking.
• For example, these patients can discuss in detail an event in their lives,
but an hour later might not remember ever having the conversation.

28. Brain injury
% who experienced each
type of ABI
mean number of incidents
among those who
experienced each ABI
Traumatic brain injury (TBI) 59.2 7.6
Hypoxic events 53.1 4.3
Alcohol related brain injury
(ARBI)
65.3 16.9
Infectious processes 6.1 0.5
• Prevalence of any acquired brain injury (ABI) 88%
• Montreal cognitive assessment ; mild cognitive impairment
• similar scores to people with Alzheimer's Disease
• Brief Symptom Inventory scored in 98th percentile for psychological distress
Suggests there is a need for neuropsychological assessment in this group.

29. So, what will we see?
• More older Australians who are homeless and alcohol dependent
• Poor mental health : mood and anxiety disorders, psychoses and cognitive
disorders e.g dementia, delirium and Wernicke-Korsakoff syndrome.
• Poor physical health: osteoporosis; ischemic heart disease, stroke, type 2
diabetes, colorectal cancer, infection, poor dental care, , lung cancer
bronchitis (smoking), falls, liver cirrhosis, dementia, and adverse events
arising from medication mismanagement.
• End stages of long standing BBVs – HIV, Hep C, Hep B
• Increased social exclusion: sever links with family and non-drug using friends,
death of partners

30. What it means for housing
• Housing that accommodates any disabilities, does not require
extensive maintenance and located close to amenities and public
transport.
• Located in familiar neighbourhoods.
• Home based care with integrated services – allows for ageing in place
• Successful housing associated with previous stable accommodation
history, revived contacts with family, taking up activities, regular help
from housing support workers
• Gold standard services EXIST eg Wintringham

31. Conclusions
• “Irrespective of presence of brain injury or anti-social behaviour these
individuals are entitled to receive care and support that is both appropriate
to their needs and which promotes empowerment and independence”
• Housing should meet the needs and requirement of this group
BUT
• Lack of affordable housing appropriate to needs of older with
substance use disorders
• Lack of sufficient income to maintain an adequate standard of living

32. “Individuals who are most marginalised will carry
the burden”
Further details: Lucy Burns l.burns@unsw.edu.au
THANK YOU