EFFECTS OF SUBSTANCE ABUSE AMONG THE ELDERLY PEOPLE LIVING IN RACECOURSE WARD, KESSES SUB COUNTY, UASIN GISHU COUNTY

CHAPTER ONE

INTRODUCTION

1.1 Overview

This chapter discusses the background of the study; statement of the problem, objectives of the study and study hypotheses. Further on, significance, scope and limitation of the study will also be discussed.

1.2 Background of the Study

Substance abuse refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs (WHO, 2015). Psychoactive substance use can lead to dependence syndrome – a cluster of behavioral, cognitive, and physiological phenomena that develop after repeated substance use and that typically include a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state (WHO, 2015). Drug and substance abuse is a problem that countries throughout the world have had to contend with for centuries. According to a report released by the Office for National Statistics in the United Kingdom (2013), the use of drugs among older people has long been an under-researched area, the importance of which has only recently become recognized. Changes in global demographics point to an increase in both the number and proportion of older people in all regions.

Globally, deaths directly caused by drug use increased by 60 per cent from 2000 to 2015. People over the age of 50 accounted for 39 per cent of the deaths related to drug use disorders in 2015. However, the proportion of older people reflected in the statistics has been rising: in 2000, older people accounted for just 27 per cent of deaths from drug use disorders. About 75 per cent of deaths from drug use disorders among those aged 50 and older are linked to the use of opioids. The use of cocaine and the use of amphetamines each account for about 6 per cent; the use of other drugs makes up the remaining 13 per cent (Mudashir, 2016).

In Europe, another cohort effect can be gleaned from data on those seeking treatment for opioid use. Although the number of opioid users entering treatment is declining, the proportions who were aged over 40 increased from one in five in 2006 to one in three in 2013. Overdose deaths reflect a similar trend: they increased between 2006 and 2013 for those aged 40 and older but declined for those aged under 40. The evidence points to a large cohort of ageing opioid users who started injecting heroin during the heroin epidemics of the 1980s and 1990s (United States, Center for Behavioral Health Statistics and Quality, 2016)

In Germany, past-year use of any drug increased more among those aged 40 and above than the younger age groups in the period 2006–2015. Drug use among those aged 18–24 showed a more modest increase (22 per cent) over the same period (Tsai, Alegría, Strathdee, 2019). The use of cannabis has also been on the rise among those aged 55–64 in some of the most populated countries in Western Europe. Annual prevalence data from France, Germany, Italy, Spain and the United Kingdom show that cannabis use among those in that age group has been increasing at a higher rate than any other age group. The increase in past-year cannabis use among those aged 15–24 and 25–34 in those countries has been much less pronounced and, in some cases, the prevalence has declined (Carew & Comiskey, 2018). In Australia, there was a small decline in the annual prevalence rate of drug use for those aged 14–19 years during the period 2007–2016, but with prevalence rates increasing by 60 to 70 per cent in the 50–59 and 60 and older age groups (Canberra, 2017).

In Chile, the past-year use of cannabis among those aged 45–64 showed a fourfold increase over the decade to 2016, and an almost 30-fold increase between 1996 and 2016. The rise in the annual prevalence of cannabis use was less pronounced among younger age groups. A similar pattern was also revealed for the use of cocaine: the annual prevalence of use declined for those aged 12–18 and 19–25 during the period 1996–2016, but increased 14-fold among those aged 35–44 (Kerr, Camillia Lui and Yu Ye, 2017).

In Nigeria, one in seven persons aged 15-64 years had used a drug (other than tobacco and alcohol) in the past year. The past year prevalence of any drug use is estimated at 14.4 per cent (range 14.0 per cent 14.8 per cent), corresponding to 14.3 million people aged 15-64 years who had used a psychoactive substance in the past year for non-medical purposes. Among every 4 drug users in Nigeria 1 is a woman. More men (annual prevalence of 21.8 per cent or 10.8 million men) than women (annual prevalence of 7.0 per cent or 3.4 million women) reported past-year drug use in Nigeria. The highest levels of any past-year drug use were among those aged 25-39 years (UNGASS, 2016).

In Kenya, older people report a higher use of established substances such as khat in different forms (Miraa and Muguka) and cannabis (bhang and hashish), while drugs that have become available in Africa more recently, such as cocaine and heroin, are reported to be used more frequently among those aged 18–24. Among the general population, khat and cannabis remain the two most commonly used substances, with the highest lifetime and past-year use among those aged 25–35. Conversely, the lifetime use of cocaine, heroin and prescription drugs is nearly three times higher among people aged 18–24 than among those aged 36 years and older (NACADA, 2018)

The problem of drug abuse is slowly gaining momentum in major urban centres of Kenya. It is presumed to have a high prevalence in Uasin gishu, Mombasa, kisumu and Nairobi Counties because of their Status. This presumption is buttressed by past anecdotal media accounts of widespread use and (suspected) serious adverse drug reactions. These had led many women and religious groups to publicly protest, asking for better enforcement of the laws against some of these drugs. The opportunity for rational debate and effective policy making has also been limited. Policy measures that reflect such errors may be regarded as disproportionate and illegitimate by sections of society that are the intended focus, which in turn could bring about unintended harmful consequences. A country-wide needs assessment study undertaken in 1994 by the Government of Kenya and the United Nations International Drug Control Programme (UNDCP) revealed that drug abuse has permeated all strata of Kenyan society, the elderly people being the most affected groups. New psychoactive substances pose a particular challenge to those formulating drugs’ policy and related public health responses targeting these segments of the population (Gathu & Gakunju, 2013).

1.3 Problem Statement

Substance abuse is a growing, but mostly silent, epidemic among older adults. In Kenya, reports of Elderly people’s lives destroyed by alcohol and drugs are rampant (Muchemi, 2013). The changing demographic composition of the older adult population affects not only the prevalence of substance abuse, but also the need for a variety of services, including treatment. It is estimated that the number of older adults who will need treatment for substance abuse has increased. This increase is partially attributed to the aging population who has had more exposure to drugs, alcohol and tobacco from a younger age, which is reported to be a risk factor for use and abuse of these substances in later years (World Health Organization, 2013). The use of illicit drugs among older adults appears to be increasing. A study showed that the use of illicit drugs among adults age 50–59 almost doubled between 2012 and 2017 (5.1% to 9.4%). Also, of the adults aged 50–59 who were using illicit drugs in 2017, almost 90% had started using them before age 30. This implies lifelong nature of illicit drug use . Analysis of the 2015 data from the Drug Abuse Warning Network surveillance system showed that of the 1.1 million emergency department episodes for adverse drug reactions, 61% were for persons aged 65 or older. Also, almost 25% these episodes were due to adverse reactions to central nervous system drugs (WHO, 2018). Although limited, research indicates important differences in the effects of substance abuse in older adults. This study therefore seeks to assess the effects of substance abuse among the elderly people living in racecourse ward, Kesses Sub County, Uasin Gishu County.

1.4 Research Objectives

1.4.1 General Objective

The general objective of this study will be to assess the effects of substance abuse among the elderly people living in racecourse ward, Kesses Sub County, Uasin Gishu County.

1.4.2 Specific Objectives

1. To identify the types of drugs those are commonly abused by the elderly people living in racecourse ward.
2. To find out the risk factors and dangers of substance abuse among the elderly people living in racecourse ward.
3. To analyze the effects of effects of substance abuse among the elderly people living in racecourse ward.
4. To find out the ways of curbing substance abuse among the elderly people living in racecourse ward.

1.5 Research Questions

1. What are the types of drugs commonly abused by the elderly people living in racecourse ward?
2. What are the risk factors and dangers of substance abuse among the elderly people living in racecourse ward?
3. To what extent do you agree on the effects of effects of substance abuse among the elderly people living in racecourse ward?
4. What are the ways of curbing substance abuse among the elderly people living in racecourse ward?

1.6 Significance of the Study

This study will reveal the types of drugs available to the elderly, the risk factors and dangers of substance abuse, effects of effects of substance abuse and ways of curbing substance abuse among the elderly people. These findings will be useful to county government and even other stakeholders in Kenya such as the NGOs and BOGs who will then be able to devise measures that will ensure that elderly people do not abuse drugs. Furthermore, the findings of this study will assist the in organizing seminars and workshops within the community to enhance knowledge on drug abuse and the factors influencing their use. The NGOs will be provided with information on the influence of the mass media as far as drug abuse is concerned and will be able to come up with ways of influencing them to reduce advertisements on drugs while at the same time offering programmes that will educate the public on substance abuse.

1.7 Scope of the Study

The study will focus on elderly people living in racecourse ward; Kesses sub County of Uasin Gishu County as defined by the respective boundaries. The study will assess the effects of substance abuse among the elderly people. It will be limited to risk factors and dangers of substance abuse, effects of effects of substance abuse, ways of curbing substance abuse among the elderly people. The study will adopt a qualitative research design. Data will be collected by use key informant interviews. The study will be conducted between the months of April and August 2020.

1.8 Justification of the study

Substance abuse among the elderly is one of the fastest growing health problems globally. Addiction among the elderly is often underestimated and under-diagnosed, which can prevent them from getting the help they need (Kuerbis,Sacco, Blazer, and Moore, 2014). Alcohol and prescription drug abuse affects up to 17% of adults over the age of 60 as per the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Due to insufficient knowledge, limited research data, and hurried office visits, health care providers often overlook substance abuse among the elderly. This is made worse by the fact that the elderly often have medical or behavioral disorders that mimic symptoms of substance abuse, such as depression, diabetes, or dementia (Bogunovic, 2012). In addition limited studies have been done with regard to drug abuse among the elderly thus raising the question on the effects of substance abuse among the elderly people

CHAPTER TWO

LITERATURE REVIEW

2.1 Overview

This chapter reviews the literature available on drug abuse among the elderly. It will summarize the information from other researches carried out in the same field of study.

2.2 Concept of Drug Abuse

A drug is any natural or artificially made chemical that changes the functions or structure of the body in some way (Tabifor, 2000). Drug abuse is the non-medical use of drugs (Ndetei, 2004). Drugs modify behavior of the people who abuse them (Tony, 2000). Substances are classified according to their effects in the body systems. Depressants such as alcohol slow down the nervous system and impair thought and judgment. Narcotics, which include heroine and morphine, also slow down the nervous system and relieve pain. Stimulants, for instance tobacco and khat stimulate the central nervous system (CNS). This leads to increased activity and mood elevation. Hallucinogens such as bhang stimulate and suppress the CNS and therefore cause distortion in perception (Ndetei, 2004).

Globally, substance/drug abuse resulted in some 3 million deaths (5.3% of all deaths) worldwide and 132.6 million disability-adjusted life years (DALYs) – i.e. 5.1% of all DALYs in 2016. Mortality resulting from substance/drug abuse is higher than that caused by diseases such as tuberculosis, HIV and AIDS and diabetes. Among men in 2016, an estimated 2.3 million deaths and 106.5 million this were attributable to the consumption of alcohol. Women experienced 0.7 million deaths and 26.1 million attributable to alcohol consumption (Degenhardt et al, 2018)

In 2016, of all deaths attributable to substance/drug abuse worldwide, 28.7% were due to injuries, 21.3% due to digestive diseases, 19% due to cardiovascular diseases, 12.9% due to infectious diseases and 12.6% due to cancers. About 49% of alcohol attributable DALYs are due to noncommunicable and mental health conditions, and about 40% are due to injuries (Degenhardt et al, 2018). There are significant gender differences in the past 12-month prevalence of alcohol use disorders. Globally an estimated 237 million men and 46 million women have alcohol use disorders (WHO, 2018).

According to Degenhardt et al (2018), 3.7% of the global burden of disease is attributable to tobacco use. Disorders due to psychoactive substance use – including alcohol, drug and tobacco dependence are the main underlying conditions ultimately responsible for the largest proportion of the global burden of disease attributable to substance use. A study conducted by the National Authority for the Campaign Against Alcohol and Drug Abuse (NACADA) in 2012 revealed that at least 13.6 percent of Kenyans aged 15-65 years were current users of alcohol. The current usage of other drugs and substances of abuse stood at 9.1% tobacco, 4.2% khat / miraa, 1.0% bhang / marijuana, 0.1% hashish and 0.1% heroin (NACADA, 2012)

Analysis of current alcohol use showed that the prevalence was highest in Nairobi, Western and Eastern regions. Findings also showed that the prevalence of current use of alcohol was highest among male respondents and those from urban areas. On a national level, the current alcohol use among respondents aged 15 – 65 year showed a decline from year 2007 to year 2017 (NACADA, 2018). According to the WHO (2018), globally, projection to 2025 shows that alcohol consumption will increase but the prevalence rate of current use will continue to decline

Alcohol and Drug Abuse is one of the major social problems in Kenya with common and easily identifiable manifestations in public health. Half of drug abusers in Kenya are aged between 10- 19 years with over 60% residing in urban areas and 21% in rural areas (UNODC, 2017). The median age of first use of chang’aa and cigarettes is 9 years and by age ten, half of these children have tried chewing/sniffing tobacco, traditional liquor and miraa. The median age of use of packaged alcohol is 11 years while that of bhang is 14 years (NACADA, 2017). In Kenya, the majority hold positive attitudes towards consumption of illicit drugs such as cigarettes (73%), packaged liquor (72%), traditional brew (69%), other tobacco products (68%) and miraa (54%). Clearly, there is a widespread attitude that if a drug is legal, it is alright to use. In contrast, illicit drugs have particularly low acceptability ratings. At least 13 percent of people from all provinces in Kenya except North Eastern Province are consumers of alcohol. Overwhelming majority of tobacco smokers smoke every day (90%), while slightly over 70 percent of miraa users and people who sniff or chew tobacco products use the substances daily(NACADA, 2018).

2.3 Types of drugs those are commonly abused by the elderly people

2.3.1 Alcohol

Alcohol (ethanol) is a CNS depressant, exerting its effects by several mechanisms. It binds directly to γ-amino butyric acid (GABA) receptors in the CNS, causing sedation and directly affecting cardiac, hepatic and thyroid tissues. Large amounts consumed rapidly or chronically can cause respiratory depression, coma and death. Alcohol withdrawal manifests as a continuum, ranging from tremors to seizures, hallucinations and life-threatening autonomic instability in severe withdrawal (delirium tremens –DT). Detoxification is mainly done as an inpatient procedure and regular monitoring of vital signs is absolutely essential. Symptoms of alcohol effects on an individual are proportionate to the Blood Alcohol Concentration (BAC). 0.1% BAC is equivalent to 100 mg alcohol in 100ml blood (Mutie, 2006).

2.3.2 Methanol

Methanol is a product of poorly adulterated alcoholic beverages and its toxicity is a common occurrence in many parts of the developing world especially among members of the lower socioeconomic status. Methanol is also known as industrial or wood alcohol and is mixed up with ethanol that is used for medical purposes. It is a commonly used organic solvent in printing and copy solutions, adhesives, paints, polishes and stabilizers. It is also used for window cleaners, antifreeze, as a fuel in alcoholic lamp and as an additive in gasoline (Ministry of Health, 2018)

According World Health Organization (2018) methanol is sometimes used to fortify illicit spirits and home-made brews. Some unscrupulous dealers may package methanol as ethanol. Methanol as an alcohol is rapidly absorbed through the gastro-intestinal tract, so the average absorption half-life is 5 minutes and reaches maximum serum concentration within 30-60 minutes and well dissolves in body water. Methanol is not toxic by itself, but its metabolites are toxic. Lethal dose ranges from 60ml – 240ml. Methanol is metabolized in many phases, mainly in the liver, the initial enzyme in its metabolism being alcohol dehydrogenase (ADH). Formaldehyde dehydrogenase (FDH) and 10-formyl tetrahydrofolate synthetase (F-THF-S) are also enzymes involved in methanol metabolism

Clinical manifestation of poisoning with methanol alone generally occurs within 30 minutes to 4 hours of ingestion. They include nausea, vomiting, abdominal pain, confusion, drowsiness and central nervous system depression. Patients usually do not seek help at this stage. After a latent period of 6 to 24 hours that depends on the dose absorbed, decompensate metabolic acidosis occurs, which induces blurred vision, photophobia, changes in visual field, accommodation disorder, diplopia, blindness and less commonly, nystagmus. Blurred vision with unaltered consciousness is a strong suspicion for methanol poisoning. Other signs and symptoms may include increased heart and respiratory rate, hypertension and altered mental status. Pulmonary oedema, acute respiratory distress, arrhythmia, heart failure, drowsiness, seizures, stupor, opisthotonus, coma and death may occur (World Health Organization, 2018).

2.3.3 Cannabis

Cannabis, also known as marijuana, grass, skunk, weed, hash and ganja is usually sold as either a dark brown lump of resin or as bags of dried herbs, flower heads and seeds. Its active ingredient is ∆-9-Tetra-Hydro-Cannabinol (THC). Within two hours of cannabis use, one may develop conjuctival injection (red eyes), increased appetite, dry mouth and increased heart rate. They also have euphoria, anxiety, impaired motor co-ordination, sensation of slowed time and impaired judgement. Heavy users tend to smoke cannabis more frequently after building up a tolerance to the drug. Regular use of cannabis especially at an early age and amongst the young people results in a range of long-term effects and risks, which include social withdrawal, lack of motivation (Amotivational Syndrome), high blood pressure, heart problems and breathing problems like asthma. Short-term memory loss, concentration problems, psychosis and depression can also occur (NAcada, 2018)

2.3.4 Nicotine

Nicotine is present in tobacco products. Tobacco products come in various forms such as cigarettes, shisha, ‘kuber’, ‘snuff’ and chewable forms. Nicotine is a highly addictive drug. Smoking is not only a physical addiction, but also becomes linked with many social activities and coping needs, making it a difficult habit to break. When an individual who is addicted to nicotine stops smoking, they may experience withdrawal symptoms such as increased anger, hostility and anxiety. A smoking cessation program should be encouraged during the early phases of drug dependency treatment (Kamenderi, 2018)

2.3.5 Khat

Khat is a natural stimulant from the Catha edulis plant, found in the flowering evergreen tree or large shrub which grows in East Africa and Southern Arabia. It is also known as Miraa, Catha, Quat, Chat, Muguka, Abyssinian Tea. Khat leaves contain a psychoactive substance called cathinone, which is structurally and chemically similar to d-amphetamine and cathine, a milder form of cathinone. When fresh khat leaves are chewed over several hours, they produce a mild cocaine-like or amphetamine-like euphoria and generate intense thirst. Khat is a sympathomimetic and its pharmacological effects are believed to parallel those of amphetamines. Psychiatric manifestations induced by khat are similar to the effects of other known stimulants. After ingestion of khat, one may present with euphoria of affective blunting, hypervigilance, anxiety, tension, anger, impaired judgement and changes in sociability. Other signs and symptoms may include tachycardia or bradycardia, papillary dilation, elevated or lowered blood pressure, sweating or chills, nausea or vomiting and evidence of weight loss.

Cocaine Cocaine is extracted from the leaves of the coca plant, growing in the Andean mountains in South America. Street names include: coke, C, blow, Charlie, snow, dust, white, flake, mojo, paradise, nose candy, sneeze, sniff or toot. Cocaine is distributed in the streets in two main forms: cocaine hydrochloride which is a white crystalline powder and “crack”, which is cocaine hydrochloride that has been processed with ammonia or sodium bicarbonate ( baking soda) and water into a free base cocaine (chips, chunks or rocks).

Cocaine can be snorted in its hydrochloride powder form or dissolved in water and injected. Crack can be smoked and it offers a short but intense ‘high’ to the smokers. It is most commonly smoked through a pipe, the quickest way to get the drug to the brain. Glass pipes, tin cans or plastic water bottles are used as conduits. Cocaine is a powerful stimulant whose effects wear off quickly, prompting the user to repeat the dose. Its initial effect is to induce euphoria, the ‘high’ usually lasts 5-10 minutes after which the user feels depressed and low. Effects of crack cocaine include euphoria, overconfidence, loss of appetite, lack of sleep, alertness, increased energy and craving for more cocaine. The aftereffects of crack use may include fatigue, depression, paranoid ideation and depersonalization as people ‘come down’ from the high. Excessive doses can cause a range of severe medical problems such as pulmonary oedema, myocardial infarction, heart failure, cerebral haemorrhage, stroke, hyperthermia and even death. Chronic use of crack can result in some physical and marked psychological dependence. High dose users, especially of crack, are likely to need treatment for a large range of physical and psychological problems.

2.4 Risk factors and dangers of substance abuse among the elderly people

Patients aged 50–54 had the highest rates of recent illicit drug use and the percentage of participants using illicit drugs has generally increased over time for all three age groups. In another study, Simoni-Wastila and Yang (2006) reviewed over 60 studies of drug abuse among adults aged 50 and older published between 1990 and 2006. This review revealed inappropriate use of prescription drugs such as benzodiazepines and opioid analgesics. Further, this inappropriate use ranged from sharing medications, using higher doses for longer periods than prescribed, and using the medications for recreational use (e.g., for their mood-altering effects). Benzodiazepines are often prescribed to treat anxiety and sleep disturbances; opioid analgesics are often prescribed to manage chronic pain and pain related to health problems prevalent among older adults (Williams et al., 2008; Solomon et al., 2006).

A number of factors place older adults at risk for problematic substance use, including a loss of social and economic support and the presence of other life stressors such as retirement and the loss or death of a spouse (SAMHSA, 1998). Being female, being socially isolated (i.e., not having a social support system and spending a great deal of time alone), having a history of substance abuse, and having a history of mental illness are also risk factors for developing alcohol and/or drug abuse (Culberson & Ziska, 2008).

Another complicating factor involves the detection of substance abuse among older adults, which may be challenging for a number of reasons, including a general lack of awareness of the prevalence of substance use and misuse among older adults and the difficulty in separating symptoms of substance abuse from other co-occurring physical or mental health conditions (SAMHSA, 1998). In addition, assessment tools and other screening surveys for substance use may use criteria that are not applicable to older adults (for example, the impact of use on work or school performance) and may be limited in their effectiveness (SAMHSA, 2011).

The social and physical changes that accompany aging may well increase vulnerability to drug-related problems. The loss of loved ones, juggling of multiple roles, and retirement or other alterations in employment and income may cause some older people to use illicit drugs as self-medication for anxiety or depression, especially if they have a history of taking drugs to cope. Slowing metabolism can increase sensitivity to the effects of drugs. Furthermore, the effects of drugs of abuse in older adults may be influenced by age-related health conditions and medications—contingencies that are more problematic when patients hide their drug abuse (NIDA, 2011)

2.5 Effects of effects of substance abuse among the elderly people

Substance use disorders are characterized by a pattern of continued pathological use of a psychoactive substance that results in repeated adverse physiological, behavioral and social consequences. The ICD defines Dependency syndrome as: A cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had a greater value” (WHO ExpertCommittee on Drug Dependence, 1998).

Clinical research is beginning to elucidate the consequences of unrecognized substance abuse or dependence on an aging population. Complications that occur with increasing frequency with age, such as medical comorbidity, cognitive impairment, and frailty, contribute to the potential adverse interactions between substance misuse and an aging brain (Kuerbis, Sacco, Blazer & Moore, 2014).

The 2009 SAMHSA’s National Survey on Drug Use and Health revealed dramatic increases in illicit drug use in older adults, including nonmedical use of prescription drugs among women aged 60 to 64. Overall, alcohol was the most frequently reported primary substance of abuse for persons aged 50 or older. Opiates were the second most commonly reported primary substance of abuse, reported most frequently by individuals aged 50 to 59. These individuals also had the highest proportions of inpatient admissions for cocaine, marijuana, and stimulant abuse.

Wu, and Blazer (2011) indicated that aging induces physiological changes that increase susceptibility to the deleterious effects of alcohol and other illicit substances. Given these changes, the National Institute of Alcohol Abuse and Alcoholism recommends the following for men aged 65 or older: no more than 1 drink daily (ie, 12 oz of beer at 5% alcohol, or 5 oz of wine at 12% alcohol, or a 1.5-oz shot of hard liquor at 40% alcohol), a maximum of 2 drinks on any occasion, and even lower limits for women. These recommendations highlight how alcohol use in the elderly can potentially be problematic, even if it does not cause abuse or dependence (Kuerbis, Sacco, Blazer & Moore, 2014).

Older adult substance abusers can be categorized as early-onset or late-onset abusers. In early-onset abusers, substance abuse develops before age 65. In these individuals, the incidence of psychiatric and physical problems tends to be higher than that in their late-onset counterparts. It is estimated that early-onset substance abusers make up two-thirds of the geriatric alcoholic population. In late-onset substance abusers, these behaviors are often thought to develop subsequent to stressful life situations that include losses that commonly occur with aging (eg, death of a partner, changes in living situation, retirement, social isolation). These individuals typically experience fewer physical and mental health problems than early-onset abusers (Center for Behavioral Health Statistics and Quality, 2015).

Common medical consequences include liver damage; immune system impairment; and cardiovascular, GI, and endocrinological problems.Elderly patients often present to the emergency department with severe illness. Symptoms of alcohol withdrawal are missed and are easily attributed to a cause other than alcohol abuse (Kuerbis, Sacco, Blazer & Moore, 2014).. Alcohol withdrawal disorders include tremulous syndrome, hallucinations, seizures, and delirium tremens. Although there is no evidence that the disorders occur at different rates in the elderly, data from animal studies show increased severity of symptoms. The prevalence of alcohol-related dementia in late life differs depending on the diagnostic criteria used and the population studied; however, there is general consensus that alcohol contributes to cognitive deficits. George, Landerman, Blazer, and Anthony (1991) states that substances such as opioids and benzodiazepines also increase the risk of cognitive impairment that ranges from confusion to delirium to dementia

The treatment of co-occurring disorders in patients with mental illness presents unique challenges. The literature, although extensive for younger adults, is almost nonexis-tent for older adults. An integrated approach to treatment of co-occurring disorders in severe mental illness provides better outcomes (Kranzler and Rosenthal, 2003). Using a multidisciplinary team to treat co-occurring disorders enhances cohesiveness of care and reduces conflicts between treaters. Both disorders should be treated as primary using a combination of different modalities, such as effective outreach and case management, motivational techniques, psychotherapy, and psychopharmacology (Center for Behavioral Health Statistics and Quality, 2015).

2.6 Ways of curbing substance abuse among the elderly people

An effective national system for the effective treatment of substance use disorders requires a coordinated and integrated response of many actors to deliver policies and interventions based on scientific evidence in multiple settings and targeting different groups at different stages with regard to the severity of their substance use disorder. According to WHO, (2016) the public health system is best placed to take the lead in the provision of effective treatment services for people affected by drug use disorders, often in close coordination with the social care services and other community services. At the systems level it needs to be ensured that treatment services are: Available, Accessible, Affordable, Evidence-based and diversified when developing a comprehensive treatment system it is wise to allocate available resources and respond best to patient’s needs. The key public health principle to apply is offering the least invasive intervention possible with the highest level of effectiveness and the lowest cost possible. This is an important principle when designing or reviewing a treatment system and taking into account the treatment standards (NACADA, 2016). In engaging older adults in substance abuse treatment, it’s important to understand that older adults who do not have a history of lifelong, hard-core addiction are usually reluctant to be associated with what are stereotypically known as down-and-out alcoholics or drug addicts. They need to be understood and treated in contexts that are more comfortable for them.

2.6.1 Psychosocial Interventions

This is an umbrella term that covers an array of non-pharmacological interventions for effective management of drug use. Psychosocial interventions help address motivational, psychological and environmental factors that contribute to use of alcohol and other drugs. They enhance pharmacological treatment efficacy by increasing medication compliance, retention in treatment, and acquisition of skills that reinforce the effects of medication. This helps promote abstinence and relapse prevention (World Health Organization, 2018).

Pyschosocial interventions refer to management of psychological and social behaviors involved in or contributing to alcohol and drug use disorders. Clients with problematic alcohol and drug use disorders report multiple health and social problems. It is often difficult to establish whether these problems were cause or effect of the clients alcohol and drug use. For example, peer influence will exert considerable influence on problematic alcohol and drug use disorders, with clients often limiting their social networks to those that reinforce alcohol drinking and drug use disorders (Jernigan and Babor, 2015).

Environmental factors such as housing and general living conditions are psychosocial factors that need to be assessed and be included in any treatment plan. They are important for management and relapse prevention. These interventions range from psycho-education on the effects of alcohol and other drugs, support through drug withdrawal, motivational counseling, behavioral therapy, orientation to self-help groups and social services and appropriate referrals for ongoing care after discharge. The specific types of intervention, amount and duration depend on the nature, complexity and temporal pattern of the alcohol and substance use, as well as presence of additional physical and psychiatric disorders. In order to choose the appropriate intervention, it is important to conduct a psychosocial assessment which includes: history of drug use, motivation and readiness to change, family history, vocational history and treatment history (World Health Organization, 2018).

2.6.2 Pharmacological Interventions

Medical Detoxification is the management of withdrawal drug use in order to arrest or reduce the acute physical and psychiatric symptoms and other concurrent drug use and health problems among persons with severe dependence, and to reduce future relapse. Pharmacological or non-pharmacological interventions can be use, depending on the nature of drug use, and they may be delivered as either out-patient or in-patient/residential services. Treatment of withdrawal is of the foremost concern if a patient has had a protracted and severe recent history of alcohol, opioid, benzodiazepine or barbiturate use. Unrecognized and untreated withdrawal can drive a patient out of treatment (NACADA, 2017)

Medical detoxification can be done both at outpatient and in-patient levels, depending on severity of the condition and the type of drugs used. Each case should be handled on the basis of a careful assessment of the client, especially in clients who present with acute medical and psychiatric problems, especially seizures and depression and concurrent acute alcohol dependence. Stabilization of acute withdrawal problems is typically complete within 3-5 days, but may be extended for patients with co-morbidities. Psychological interventions and education must be initiated during the detoxification process (WHO, 2016)

2.6.3 Community interventions

Recovery-oriented care includes the Strengths-Based Case Management which views recovery as more than the achievement of abstinence from drug use, but to also as a means to build meaningful and satisfying lives which will become a strong buffer against relapse. This approach is characterized by: Focus on increasing strengths rather than reducing deficits: It seeks to identify, nurture and further develop a client’s skills, talents, resources, and interests rather than emphasizing needs, deficits, and pathologies (Dowell, Haegerich and Chou, 2016)

Flexible rather than fixed approach: A recovery-supporting program must respond to patient changes through modifications made over time, offering choice by providing a flexible range of supports and services to meet needs of the individual patient. Consideration for patient’s autonomy: Recovery management is a self-directed approach, rather than a mandated non-voluntary program, that encourages and supports individuals in making informed choices about their life and treatment. The importance of incorporating patient choices has been stressed in other areas of medicine, especially with regards to the management of chronic diseases, and was found to increase individual’s responsibility for their recovery (WHO, 2016).

Participation of

: Recovery management involves family, friends, and the whole community to strengthen social aspects of recovery as opposed to overcoming addiction in isolation. It encourages others to play a role in the recovery process and draws on the resources of the community, including professional and non-professional organizations, faith based organizations, and schools. Members of family and community organizations are incorporated, when appropriate, in recovery implementation (Dowell, Haegerich and Chou, 2016)

2.6.4 Community corrections

Community correction is another alternative to incarcerating individuals who have serious drug use problems. Terms of supervision are placed on the individual with the threat that a violation could result in incarceration. In addition to taking random drug tests, being subject to home inspections, and remaining drug-free, supervision requirements may need one to participate in treatment services. For the most serious offenders, intensive supervision probation (ISP) is often used and includes more frequent monitoring by the low enforcement practitioners as well as more frequent meetings(Nicholas, Lee and Roche, 2011)

The use of day reporting is another option where individuals much report to a location like a probation office on a frequent (usually daily) basis. In some jurisdictions, there are treatment options dedicated to those under ISP and day reporting supervision. Alternatively, “halfway houses” are provided when there is a need for intermediate housing during the transition from prison to the community. Individuals are required to remain within the halfway house when not at work, at court, or seeking medical treatment. Halfway houses typically provide 12-step support groups and, in some cases, provide treatment options dedicated for those residing within the halfway house (Nicholas, Lee and Roche, 2011).

CHAPTER THREE

RESEARCH METHODOLOGY

3.1. Overview

This chapter is a blueprint of the methodology that will be used to find answers to the research objectives. It covers the research design, target population, sample size, sampling method, data collection method, reliability and validity, data analysis methods and ethical considerations.

3.2 Study Design

This is a cross sectional study. Cross-sectional study is one of the most widely used non-experimental research designs across disciplines to collect large amounts of survey data from a representative sample of individuals sampled from the target population (Cooper &Schindler, 2011). Creswell (2003) observe that cross -sectional survey research design is used when data are collected to describe persons, organizations setting or phenomena. A cross-sectional study design is used when the purpose of the study is descriptive, often in the form of a survey (Creswell, 2003).

3.3 Target Population

Blumberg, Cooper and Schindler (2014), defines population as all the fundamentals that rally the basis for inclusion in a study. The study population will be the residents of race course ward who are above 18 years. According to the KNBS census 2019, race course ward had a population of 22,666 residents out of this 10,776 were above 18 years. The study will therefore target 10776 respondents.

3.3.1 Inclusion criteria

The study will include all respondents willing to participate after giving informed consent.

3.3.2 Exclusion Criteria

The study will exclude all residents not willing to participate in the study and the residents meeting the inclusion criteria but mentally unstable

3.4 Sample Size and Sampling Technique

3.4.1 Sample size determination

According to Mugenda and Mugenda (2003), for a population of less than 100, 100% of the population is taken to calculate the sample size, for a population of between 100 to 1,000, 30% of the population is taken, for a population of 1,000 – 10,000, 10% of the target population is taken to represent the target population and finally for any target population above 10,000, 1% is taken to calculate the sample size to be employed in the study. Therefore the study selected 10% of the target population. Therefore the study sampled 108 respondents.

3.4.1 Sampling Technique

Consecutive sampling technique will be used in selecting respondents in to the study. respondents who have fulfilled the inclusion criteria will be consecutively sampled until a sample size of 108 subjects are achieved.

3.5 Research Instrument

The study will use structured questionnaires to collect data from respondents. The questionnaires will be well-situated for the assignment because they could be simply and expediently administered to the study sample. The use of questionnaire will be done because it is less costly and less time consuming as compared to other methods. The questionnaires will consist of open ended and closed ended questions and it will be sub divided into sections to capture the responses and details that are required. Questionnaires will be administered by the researcher with the research assistants directly to the respondent and a follow up will be conducted to ensure the questionnaires are filled in accordance with the research.

3.6 Data Collection Procedure

The research assistants will be trained for two days on how to collect data, they will be asked questions at a time and in turn check (by ticking) the appropriate response as guided by the questionnaire. This will be repeated for each serialized question until all the questions in all the sections will be answered.

3.7 Pre-testing of Research Instruments

A pilot test will be done before embarking on actual data collection activity. Kombo and Tromp (2009) describe a pilot test as a replica and rehearsal of the main survey. Dawson (2002) states that pilot testing assists researchers to see if the questionnaire will obtain the required results. Polit and Beck (2003) describes a pilot study as a small scale version or trial run done in preparation for a major study. Cooper and Schilder (2011) agree that the respondents used in pilot test should constitute 10 percent of the sample used in data collection. The proportionate sample size of 108 respondents will be used for the study. Therefore 10 questionnaires will be administered in pilot testing to test the degree of accuracy of the instrument used. The pilot study will be done at Langas ward because the study population has the same characteristics. The purpose of the pilot study will be to test the feasibility of the study and necessary corrections to be undertaken.

3.7.1 Reliability of the Research Instruments

Reliability test will be conducted as a test of whether data collecting instrument will yield the same result on repeated trials. A statistical coefficient – Cronbach’s alpha (α) will be used as a measure of internal reliability (Cronbach, 1971). Cronbach’s alpha reliability coefficient ranges between 0 and 1. Reliability coefficient of 0 implies that there is no internal reliability while 1 indicated perfect internal reliability. The recommended value of 0.7 will be used as a cut-off of reliability (Sekaran, 2009).

3.7.2 Validity of the Research Instruments

Validity is the degree at which data collecting instrument measures what it is supposed to measure (Cooper &Schilder, 2011). Zikmund et al., (2010) describes validity as the accuracy of data collecting instruments. It will help in determining whether the respondents understand the direction and instruction on instruments (Cooper &Schilder, 2011). The study will use content validity to test the accuracy of data collecting instruments. A judgment procedure of assessing whether a tool is likely to provide contents valid data is to request opinion of expert in a particular field to review it and give suggestions on content improvement (Mugenda, 2008). Opinion of research supervisors will be sought to review data collecting instruments. This will help to improve the instruments before proceeding to the field for final data collection. Results of their responses will be analyzed to establish the percentage of representation

3.8 Data Management

The data collected will be coded to make the data entry easy. All raw data will be reviewed by the principal investigator and crosschecked to ensure completeness; any clarifications to be made will be sought out immediately. The filled questionnaires will be kept in a safe and confidential place that will be accessible only to the principal investigator, ready for the data entry. After cross checking the information in the instruments for any missing entries a database will be designed in SPSS which will allow the researcher to set controls and validation of the variables. On completion of the data entry exercise summaries will be used for data interpretation and discussion.

3.9 Data Analysis

The data will be cleaned coded, entered and analyzed using SPSS. Descriptive and inferential statistics will be used for quantitative data analysis. Descriptive statistics will consist of frequencies, means and standard deviation. This will be used to describe the distribution of data. In addition, inferential statistics using Chi square will be used to test the association between independent and dependent variables and odds ratio used to assess the strength of the relationship between the explanatory and outcome variables.

3.10. Ethical considerations

In research, issues may arise unanticipated. According to Ritchie and Lewis(2003), the researcher needs to give careful consideration of ethical issues. The researcher is aware of challenges this may present and therefore considerable time was taken to address issues such as informed consent, confidentiality, anonymity, gaining ethical approval and the role of the researcher. To ensure ethical conduct of the study, clearance will be sought from Moi University and ethical clearance for IREC. This is because a permit is a requirement of the law of Kenya before carrying out research. Permission to conduct the study will be sought from ward administrator. Consent from the participants will be sought after informing them of the purpose of the study, the tool to be used and information needed. Participation will be on a voluntary basis and no one will be coerced. The study participants will be informed of their freedom to withdraw from the participation at any stage and that will not affect their studies at the clinical area.

REFERENCE

Center for Behavioral Health Statistics and Quality. (2015). Results from the 2014 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs2014/NSDUH-DetTabs2014.pdf

Degenhardt, L., Charlson, F., Ferrari, A., Santomauro, D., et al. (2018). “The global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990– 2016: a systematic analysis for the Global Burden of Disease Study 2016.” The Lancet Psychiatry, 987 – 1012

George LK, Landerman R, Blazer DG, Anthony DC. Cognitive impairment. In: Robins LN, Reiger DA, eds. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. New York: Free Press; 1991:291-327

Hanefeld, J., Hawkins, B., Knai, C., Hofman, K. and Petticrew, M. (2016). What the InBev merger means for health in Africa. BMJ Glob Health; 1: e000099.

Jernigan, D. H. and Babor, T. F. (2015). The concentration of the global alcohol industry and its penetration in the African region. Addiction; 110: 551–60.

Kamenderi,

M, (2017) Status of Drugs and Substance Abuse among the General Population in Kenya. African Journal of Alcohol & Drug Abuse : Edition

Kranzler HR, Rosenthal RN. Dual diagnosis: alcoholism and co-morbid psychiatric disorders. Am J Addict. 2003;12(suppl 1):S26-S40.

Kuerbis, A., Sacco, P., Blazer, D. G., & Moore. A. A. (2014). Substance abuse among older adults. Clinics in Geriatric Medicine, 30(3), 629–654.

Mattson, M., Lipari, R.N., Hays, C. and Van Horn, S.L.(2017)A day in the life of older adults: Substance use facts. The CBHSQ Report:

Mutie, P. (2006). National AIDS Control Council. Maisha News letter. Second Quarter 2006/7. Nairobi – Kenya. Pg. 4-20

NACADA (2012). Rapid situation assessment of the status of drug and substance abuse in Kenya. NACADA, Nairobi.

NACADA (2015) National Survey on Alcohol and Drug Abuse among Secondary Students in Kenya 2016.

NACADA (2017). Rapid situation assessment of the status of drug and substance abuse in Kenya. NACADA, Nairobi.

National Institute on Aging. (2011, June). Older adults and alcohol: You can get help. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services. Retrieved from https://www.nia.nih.gov/health/publication/older-adults-and-alcohol/whats-inside

NIDA. (2011, December 19). Substance Abuse Among Older Adults. Retrieved from https://archives.drugabuse.gov/news-events/nida-notes/2011/12/substance-abuse-among-older-adults on 2020, May 13

UNDG (2015). “Mainstreaming the 2030 Agenda for Sustainable Development- Interim Reference Guide to UN Country Teams.” Geneva.

UNODC (2017). World Drug Report. UNODC, Vienna, Austria.

WHO (2015) Self-help strategies for cutting down orstopping substance useguide

World Health Organization (2018). Global Status Report on Alcohol and Health. Geneva

Wu, L. T., & Blazer, D. G. (2011). Illicit and nonmedical drug use among older adults: A review. Journal of Aging and Health, 23(3), 481–504. doi:10.1177/0898264310386224

(6} ‘X1