Booze, Drugs and Old Folks

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Booze, Drugs and Old Folks

• Michelle Gibson
• Division of Geriatrics

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Objectives

• Participants will be able to
• Recognize substance abuse and dependence in the
  elderly, including atypical presentations
• Describe the impact of substance issues on common
  medical problems
• Manage medical complications of substance abuse
  and dependence
• Avoid causing substance-related problems!

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Substance Dependence

• Maladaptive pattern, significant impairment or
  distress, and 3 or more of
• Tolerance
• Withdrawal
• Larger amounts than intended
• Unsuccessful efforts to cut down
• Significant amount of time spent on the substance
• Reduced activities 2o to substance
• Persistent use despite problems

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Substance Abuse

• Maladaptive pattern, significant impairment or
  distress, and 1 or more of
• Failure to fulfill role at work, school or home
• Physically hazardous
• Substance-related legal problems
• Persistent or recurrent social or interpersonal
  problems
• Has never met criteria for Dependence

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The Pickle Line

• All cucumbers can become pickles, but
• Once a pickle, you can never become a cucumber
  again...

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Addiction

• Primary, chronic disease characterized by
  impaired control over the use of a psychoactive
  substance and/or behaviour.
• Bio/Psycho/Social/Spiritual
• Progressive, relapsing, fatal.

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Definition of an Alcoholic

• Anyone who drinks more than their physician does!

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Whats happening in the brain?

• Modulation of reward system
• Medial forebrain bundle connects ventral
  tegmental area to nucleus accumbens
• Also pathways that project from VTA and NAcc -gt
  limbic and cortical areas
• Dopaminergic projection most implicated in reward

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Brain
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Whats happening in the brain?

• Drugs of abuse act
• directly by influencing action of dopamine
• indirectly by affecting modulating pathways such
  as GABA, opioid, serotoninergic, acetylcholine
  and noradrenergic

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Neurons
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Epidemiology - Alcohol

• Alcohol use decreases after age 60
• 6 - 16 of older men consumed 2 drinks alcohol
  per day
• 1.6 - 6.0 of older women

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Epidemiology - Alcohol

• Prevalence of problems unclear in the elderly
• Abuse or dependence 3 for men, 0.5 for women
  (community)
• A further 3-4 had problems resulting from
  alcohol, but did not meet DSM criteria
• Higher prevalence in hospitalized elderly (21 in
  one study)

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Epidemiology - Alcohol

• Incidence rates decline with age up to 60, but
• Increase after age 60, especially in men 75

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Applying DSM-IV in older adults

• Withdrawal
• often atypical
• Taking larger amounts than intended
• cognitive impairment reduces self-monitoring
• Tolerance
• can be very sensitive

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Physiologic Changes with Age
Decreased Lean Body Mass
Decreased Total Body Water
Decreased gastric EtOH Dehydrogenase
Increased Serum EtOH for a given dose
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Applying DSM-IV in older adults

• Spending much time
• may have negative effects with little use
• they take a lot of time anyway!
• Continuing to use despite adverse effects
• may not realize health effects are related
• Giving up activities
• may not have many to give up!

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Patterns of alcoholism

• Early onset vs. late onset
• Age 60 is arbitrary cut-off
• 2/3 in early onset group
• Somehow avoided usual complications - allowing
  them to get to later life

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Late-onset Alcohol Abuse/Dependence

• Usually arises in former drinkers
• Women as a greater proportion
• Three common patterns
• Onset of cognitive / functional impairment in
  functional alcoholics
• Increased sensitivity to effects of alcohol
• New problem as a result of a stressor

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Medical consequences

• HTN, CVA
• BP starts to increase at 2-3 drinks per day
• Dose response
• Less clear with stroke
• Cancer
• Head and neck, liver (usually with cirrhosis)
• Risk increases with gt2 drinks per day
• Breast in women

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Medical consequences

• Osteoporosis
• conflicting results, may be related to
  socioeconomic status - role of nutrition
• likely plays a role

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Medical consequences

• Dementia
• 1.5-4.4 times higher rate of dementia in heavy
  drinkers
• Nursing home study - 24 of patients with
  dementia!

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Medical consequences

• Trauma
• falls risk increases with level of alcohol intake
• significant with gt1000 gm/month
• implicated in 30 of suicides
• 14 of drivers in MVAs (21 in men)
• Atrial fibrillation
• maybe up to 10 of cases

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Screening

• How much do you drink in a day/week/month?
• A mere starting point
• CAGE Questionnaire- cutoff of 1
• Sensitivity, specificity 88
• Use other questions too
• MAST-G

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Standard Drinks

• 12 oz. Beer
• 5 oz. Wine
• 1.5 oz. Liquor

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Treatment

• Diagnosis is the first step
• Non-dependent individuals may respond to brief
  interventions (up to 1/3)
• Identification
• Connection to other problems
• Counselling re strategies to cut down

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Treatment

• In dependent individuals, need to assess
  withdrawal severity
• May be detoxified at home if only mild withdrawal
  symptoms in the past and if no major medical
  co-morbidities
• If major withdrawal symptoms in the past, should
  be in medically supervised setting

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Withdrawal in the Elderly

• Onset of withdrawal delayed (days)
• May be prolonged
• Often presents with confusion
• Hallucinations (visual/tactile) may persist for
  months

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Treatment of Alcohol Withdrawal

• Benzodiazepines - lorazepam 0.5 mg to 2 mg
  po/sl/im q2-4h prn
• Thiamine 100 mg iv or im, then 100 mg po 3d
• Haloperidol 1-5 mg im/po q1-4h for hallucinations
  - max 5 doses/day
• may need seizure prophylaxis with lorazepam

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After Detox - then what?

• 12 step programs effective for older patients too
• Isolation is a key problem - hook up with a
  buddy
• Inpatient may be necessary - Homewood in Guelph,
  and others

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Medical Management

• Disulfiram - may be helpful in older, socially
  stable patients
• with CAD, CVD, severe pulmonary disease, sz
  disorder or on anti-hypertensive meds more likely
  to have severe reaction if they drink
• 125 - 250 mg po daily - can last up to 7 days

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Medical Management

• Naltrexone - opioid antagonist
• decreases cravings
• monitor LFTs
• do not start if bili up, or if transaminases are
  3X normal
• contraindicated in renal failure
• will put patients on opioids in withdrawal!
• 25 mg po od 2-4 days, then 50 mg od

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WARNING!

• Giving benzodiazepines to a recovering alcoholic
  can trigger a relapse

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Benzodiazepines

• Benzo use increases with age
• Dose increases with age
• 16 of inpatients in an addiction unit -
  sedatives or hypnotics
• Women are prescribed sedatives 2.5 times more
  than men

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Benzodiazepines

• Prevalence of abuse and dependence unknown
• Likely most common prescription drug abused in
  the elderly

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Adverse outcomes

• Falls and hip fractures
• MVAs
• Cognitive impairment
• Increased dependence for ADLs and IADLs
• Depression
• Hypoxia (in sleep apnea)

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All benzos are not equal

• High dependence liability
• diazepam
• lorazepam
• alprazolam
• triazolam
• Lower dependence liability
• oxazepam
• chlordiazepoxide
• clonazepam

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Withdrawal

• Anxiety
• Dysperception
• Delirium
• Tinnitus
• Seizures
• 2-4 days after use (?applies to the elderly)
• Can go on for months

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Management of withdrawal

• Institute a tapering protocol, no more than
  10-15 per week
• may need a consult to psychiatry or physician
  with training in addiction
• May benefit from mood-stabilizers
• valproic acid, carbamazepine, gabapentin
• May benefit from trazodone

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Save yourself trouble...

• Avoid starting benzodiazepines!
• Especially avoid benzodiazepines in patients with
  previous or concurrent addiction issues
• Alternatives
• Trazodone for sleep
• SSRIs and other agents for anxiety

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Opioids

• Not really studied
• Abuse and dependence in the elderly certainly
  exists
• Again use caution in patients with previous or
  ongoing addiction issues
• Single provider, single pharmacist, contract
• Taper slowly with long-acting preparations
• May use clonidine to suppress withdrawal symptoms
  cautiously

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Summary

• Substance-related problems are common in the
  elderly
• They may present atypically
• They have significant medical consequences
• They can be diagnosed and treated effectively
• We can try not to contribute to the problem, too!

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Plato has the last word

• "I may be forgiven for saying, as a physician,
  that drinking deep is a bad practice, which I
  never follow, if I can help, and certainly do not
  recommend to another, least of all to any one who
  still feels the effects of yesterday's carouse."
• Plato's Symposium