Substance Abuse in the Elderly

1
Substance Abuse in the Elderly

• Steven W. Clay, DO
• Associate Professor
• Department of Family Medicine
• Ohio University College of
• Osteopathic Medicine

2
Objectives

• Describe Age Related Changes In The Elderly That
  Increase Their Vulnerability To The Complications
  Of Substance Abuse

3
Objectives

• Differentiate The Presentation Of Substance Abuse
  Disorders In The Elderly From That Of Younger
  Adults.
• Describe Assessment And Treatment Methods Useful
  For Elders With Substance Abuse Disorders.

4
Substance Abuse in the Elderly

• 1. The Elderly
• 2. Epidemiology
• 3. Consequences
• 4. Assessment
• 5. Treatment

5
1. The Elderly

• Demographics
• Relevant Normal Aging Changes
• Disease Presentation
• Medications

6
U.S. Geriatric Population(U.S. 2000 Census)
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The Geriatric Population

• Young-old 65-74
  Middle-old 75-84
  Old-old 85
• Fastest growth in Society is 85
• Female gt Male

8
Relevant Aging Changes

• General Changes
• Brain
• Sensory
• Stomach
• Hepatic
• Renal
• Musculoskeletal
• (Kane R L Essentials of Clinical Geriatrics 4th
  Ed. 1999 Mcgraw-Hill)

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General Physical Changes

• Body Fat Doubles to 30 -- Fat Soluble Drugs
  May Accumulate (Eg. Diazepam)
• Total Body Water Decreases -- Water Soluble Drug
  Concentrations Increase (Eg. Alcohol)

10
Brain function

• Decreased Cortical Neurons
• Decreased Brain Weight
• Blood Flow Decreased by 15 to 20
• Increased Sensitivity to Anticholinergic Drugs
  (Opiates, Etc.)

11
Sensory Loss

• Visual and Hearing Loss (More Prone to
  Confusion)
• Less Thirst Perception --Prone to Dehydration
  and Hyponatremia
• --May be Alcohol Related

12
Stomach

• Decreased Alcohol Dehydrogenase in Stomach
• Higher Blood Levels of Alcohol per Amount Consumed

13
Liver

• Decreased Liver Size
• Decreased Hepatic Blood Flow
• Limits 1st Pass Metabolism
• Drugs with Large 1st Pass Metabolism may Reach
  Toxic Levels (Eg. Opiates)

14
Liver

• Decreased Reduction, Oxidation and Hydrolysis
• Drugs May Accumulate --Barbiturates and Long
  Acting Benzodiazepines (eg. Diazepam)
• Unchanged Conjugation (Short Acting Benzos eg.
  Lorazepam)

15
Renal

• 20-30 Loss of Mass
• Loss of Function Linear with Age
• May also have Disease Related Loss of Renal
  Function
• Renal Excreted Drugs may Increase in
  Concentration

16
Musculoskeletal

• Decreased --Muscle Mass --Force of
  Contraction --Speed of Contraction.
• Slower Response to Postural Changes
• Contribute to Falls

17
Disease in Elderly

• Usually Multiple Chronic Illnesses
• May Function Well with Multiple Chronic Illnesses
  
• (Eg. DM-2, CHF, COPD, Etc.)

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Disease Presentation

• Signs and Symptoms --Less Severe --Non-Spec
  ific --Not Present
• Presentations --Delirium (Acute
  Confusion) --Functional Decline, etc.

19
Medications

• Average 4.5 Prescription Medications Per Elder
• 55-59 of Outpatient Meds With No Indication
• Many Ineffective or Risk gt Benefit (Lipton et.
  al. Med Care 1992 30 646-658) (Schmader et. al.
  JAGS 1994 42 1241-7) (Beers et. al. Arch Int
  Med 1997 157 1531-6)

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Homeostasis

• The Ability to Maintain Homeostasis is Limited in
  the Elderly --Less Reserve --More
  Affected By Stressors --Slower to Return to
  Homeostasis after Stress

21
A Matter of Balance

• Aging Processes
• Disease Processes
• Medications
• Substance Abuse

22
Substance Abuse in The Elderly

• 2. Epidemiology

23
Alcohol Over Age 65

• A Drink
• --12 Oz. Beer -- 4-6 Oz. Wine -- 1 ½ Oz
  Distilled
• Heavy Use in Elders (NIAAA)
• -- Male gt 2 / Day -- Female gt 1 / Day
• (The physicians guide to helping patients with
  alcohol problems.
• NIAAA1995, NIH)

24
Alcohol Over Age 65

• Community Elderly --Heavy Alcohol Use 3 -
  25
• --Alcohol Abuse 2 - 9.6
• Primary Care Outpatients -- 12 Women, 15 Men
  gt NIAAA Recommendations
• (Liberto et al Alcoholism in older persons A
  review of the literature. 1992 Hosp Com Psych 43
  (10) 975-84)
• (Adams et al Screening for problem drinking in
  older primary care patients. 1996 JAMA 276 (24)
  1964-7)

25
Alcohol Over Age 65

• Early Onset --Continuing gt 65 (Still
  alive) --2/3 Elders with Alcohol Abuse
• Late Onset --Mostly Previous
  Users --Increased Use --Or More Vulnerable
  to Effects
• (Blow F C Substance abuse among older adults
  Treatment improvement protocol 26 Substance
  Abuse and Mental health Services
  Administration 1998)

26
Drugs Over Age 65

• Illicit Drug Problems Rare
• in Non-Previous Addicts or Alcoholics
• (Jinks and Raschko A profile of alcohol and
  prescription drug abuse in a high-risk
  community-based elderly population. 1990 Drug
  Intel and Clin Pharm 24 971-5)

27
Drugs Over Age 65

• Opiates -- Abuse or Dependence Rare
  Unless a Addiction History
• -- Four Addicted of _at_ 12,000 Morphine
  Prescriptions (Hill and Chapman Clinical
  effectiveness of analgesics in chronic pain
  states. NIDA Research
• monograph 93 102-109 1989)

28
Drugs Over Age 65

• Benzodiazepines
• -- Chronic Use 1.8 -- Women gt Men
• 17-23 Of All Elders Prescriptions Are For
  Benzodiazepines
• (D Archangelo Substance abuse in later life.
• Can Fam Phys 39 1986-93) 1993

29
Substance Abuse in The Elderly

• 3. Consequences of Substance Abuse in the Elderly

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DSM-IV Criteria

• A Maladaptive Pattern of Use in a 12 Month
  Period
• Criteria Based Upon Consequences Common To
  Younger Adults

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Consequences Different in Elders

• Legal (Not Driving)
• Marital (Widowed)
• Occupational (Retired)
• Tolerance and Withdrawal (Difficult to Assess in
  Elders)

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Consequences of Alcohol Abuse in The Elderly

• Hypertension
• Cardiac Arrhythmia
• Myocardial Infarction
• Cardiomyopathy
• Hemorrhagic Stroke
• Impaired Immune System
• (Blow F C Substance abuse among older adults
  Treatment improvement protocol 26 Substance
  Abuse and Mental health Services Administration
  1998)

33
Consequences of Alcohol Abuse in The Elderly

• Cirrhosis And Other Liver Diseases
• Decreased Bone Density
• GI Bleeding, Malnutrition
• Depression, Anxiety, And Other Mental Health
  Problems
• Falls, Fractures
• (Blow F C Substance abuse among older adults
  Treatment improvement protocol 26 Substance
  Abuse and Mental health Services Administration
  1998)

34
Consequences of Drug Abuse in The Elderly

• Diminished Psychomotor Performance
• Impaired Reaction Time
• Loss Of Coordination
• Ataxia
• Falls, Fractures
• (Blow F C Substance abuse among older adults
  Treatment improvement protocol 26 Substance
  Abuse and Mental health Services Administration
  1998)

35
Consequences of Drug Abuse in The Elderly

• Drowsiness
• Confusion, Amnesia
• Dependence And Withdrawal
• 23 Of Adverse Drug Reactions in Nursing Home
  Setting
• (Blow F C Substance abuse among older adults
  Treatment improvement protocol 26 Substance
  Abuse and Mental health Services Administration
  1998)

36
Alcohol and Substance Abuse in The Elderly

• 4. Assessment

37
Risk Factors Alcohol

• Past History of Alcohol Use Disorder (AUD)
• Male Gender (2 X Female) -- 10 Have Hx of
  AUD -- 43 LTC Veterans Hx of AUD
• (D Archangelo Substance abuse in later life.
• Can Fam Phys 39 1986-93) 1993

38
Risk Factors Alcohol

• Loss of Spouse
• Other Losses --Health, Sensory
  Loss --Functioning, Mobility
• Family History of AUD
• Psychiatric Disorder
• Nicotine, Other Drug Use Disorder

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Risk Factors Drugs

• Female Gender
• Older Age
• Poor Health
• Divorce, Widowhood
• Anxiety, Depression, Stress
• (Gomberg ESL, Older women and alcohol use and
  abuse. In Recent developments in alcoholism
  Vol.12. Alcoholism and Women. NY, NY Plenum Press
  1995)

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Red Flags

• Cognitive Impairment
• Tremor, Seizures
• Irritability, Mood Changes, Agitation, Sleep
  Disturbance
• Unexplained Pain, Somatization
• Poor Hygiene, Neglect
• (Blow F C Substance abuse among older adults
  Treatment improvement protocol 26 Substance
  Abuse and Mental health Services
  Administration 1998)

41
Red Flags

• Abnormal LFT
• GI Complaints, Malnutrition
• Urinary Incontinence, Retention
• Slurred Speech
• Gait disturbance
• Frequent Falls, Bruising

42
Approach to the Patient

• Patients Feel Threatened
• Assure Confidentiality
• Use Non-Judgmental Approach
• Dont Rush

43
Approach to the Patient

• Better Response to Medical Approach The Alcohol
  may be Affecting Your Glucose Levels.
• Build on Problems and Causal Link with Alcohol /
  Drug Use.
• You and the Patient Against their Problems

44
Collateral Information

• Separately Talk to Others to Confirm Patients
  Story. --Spouse --Other Family --Friend
  s
• Obtain Patients Permission!

45
Screening Methods

• Alcohol -- CAGE -- AUDIT -- Max
  in Last Year
• Other Drugs -- Use Despite Consequences

46
CAGE

• C Have You Ever Felt The Need To CUT DOWN?
• A Have You Ever Been ANNOYED at Criticism Of
  Your Drinking?
• G Have You Ever Felt GUILTY About Your
  Drinking?
• E Have You Ever Had A Morning Eye-opener To
  Get Going?

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AUDIT

• Ten Questions 1st Three Questions
• Quantity / Frequency of Use
• Geriatric Primary Care Outpatients
• CAGE 5 Prevalence
• AUDIT 18 Prevalence
• Clay S W. Comparison of AUDIT and CAGE
  questionnaires in screening for alcohol use
  disorders in elderly primary care outpatients
  JAOA 97 (10) 1997 588-592

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Cognition / Function Loss

• MMSE -- Dementia
• -- Delirium
• Functioning -- ADLs -- IADLs
• Yesavage and Brink. J Psych Res 1737-49 1983

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Brief Intervention

• Feedback on Alcohol / Drug Use and Consequences
  of Use
• Reason (s) for Use
• Reasons to Cut Down / Stop -- Physical Health,
  Mental Capacity, Independence
• Goals, Written Agreement
• (Blow F C Substance abuse among older adults
  Treatment improvement protocol 26 Substance
  Abuse and Mental health Services Administration
  1998)

50
Motivational Counseling

• Readiness For Change --Pre-Contemplation
• --Contemplation
• --Preparation
• --Action
• Patients Need To Believe the Benefits of Change
• Prochaska et al Amer Psychol 47 (9) 1992

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Treatment

• Age Specific Treatment and Pace
• Focus on --Depression, Losses
  --Restoration of Self-Esteem and Social
  Supports
• Staff Experienced With Elders
• Links With Services For Elders
• Schonfield and Dupree Intl J of the Addictions
  30 1995

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Substance Abuse in the Elderly

• 1. The Elderly
• 2. Epidemiology
• 3. Consequences
• 4. Assessment
• 5. Treatment