Not fitting the boxes – caring for older marginalized citizens in Denmark

People in vulnerable positions are growing older, as is the rest of the Danish population. However, the most marginalized citizens experience significantly worse physical and mental health conditions than others. One group that particularly lags behind the rest of the population is marginalized older citizens with problematic substance use.

Despite a general increase in life expectancy in the past 10-15 years, older marginalized citizens with substance use are in worse health conditions than the average population. They experience physical and mental decline much earlier than others and die on average 17 years earlier. Accordingly, the care, support, and treatment needs in this group increase and, as the group is growing, the scope of this increases.

Most of the larger Danish cities have specialized health services targeting marginalized substance using citizens, but outside these cities, health services such as easy access to drop-in centers, street nurses, or nursing homes specifically accommodating older marginalized citizens with substance use are limited or nonexistent.

The unique anthropological study

In Denmark, the topic has until recently drawn limited attention. Therefore, we set up an explorative anthropological pilot study of health care professionals´ work in two municipalities in the Central Denmark Region in 2022. We focused on care professionals working with substance using older citizens primarily those receiving home care and, secondarily, those living in nursing homes. The overall aim was to investigate dilemmas and challenges involved in caring for older citizens with problematic, active substance.

Key findings

While the health care professionals were highly motivated to provide good services for the group, we encountered five central types of barriers and dilemmas:

1. Complex medical conditions. Substance use can have a strong negative impact on citizens´ general health conditions and can blur symptoms of more specific underlying illnesses. This can make it difficult to provide effective treatment and support for a better quality of life.
2. Ethics and autonomy. Patient autonomy is highly valued in Danish elderly care e.g. older citizens insisting on their right to drink alcohol will have the right to do so. However, this often collided with professionals’ training and values of  “proper” care including minimizing harm and “unhealthy living”.
3. Citizens´ behaviors. Unpredictable and aggressive behaviors related to e.g. excessive alcohol intake sometimes made it difficult for professionals to interact and help citizens who could be abusive or upset or would not accept assistance.
4. Not fitting into the boxes. Health care professionals reported that caring for citizens with problematic substance use often involves many different sectors and professionals. However, there was often limited systematic collaboration and exchange of relevant information between psychiatric system, substance treatment, General Practitioners and social services, which often left the care professionals on their own in navigating daily care and shifting functional levels.
5. Lack of knowledge and expertise. Several of the interviewed health care professionals called for more information and applicable guidelines to address the challenges of the target group both in relation to training, national or local knowledge and continuing education within the field.

Recommendations

Based on our findings, we point to four key areas where improvements are needed for older marginalized citizens:

• Establishing a level of specialized procedures for evaluation of older citizens with problematic substance use and how to provide health care services for them.
• Appointing local “experts” with experience and preferably also specialized training on substance use, that can be called upon for assistance locally.
• Strengthening coordination and cooperation between sectors and across professional boundaries.
• Develop easily accessible information and/or training material at a national level aimed at health care professionals who encounter substance use in their daily work (e.g. in the form of flyers, apps, Virtual Reality-tools).

By addressing these aspects, we can create more supportive services for marginalized older citizens, ensuring that they receive the care and attention they need and are entitled to.

The article is written by

Bagga Bjerge, Director, PhD, Professor, Center for Alcohol and Drug Research, Aarhus University

Jonas Strandholdt Bach, PhD, Assistant Professor, Center for Alcohol and Drug Research, Aarhus University &

Johanne Korsdal Sørensen, PhD, External Relations Manager & Head of MANTRA, Moesgaard ANThropological Research and Analysis, Department of Anthropology, Aarhus University.

on the request of PopNAD