Download GNRS4Addictions - Geriatrics Care Online

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ADDICTIONS
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OBJECTIVES
Know and understand:
• The extent of the problem of substance abuse
among older adults
• How to identify substance abuse problems
• The risks and benefits of substance use
• Strategies for treating substance abuse problems
found in older patients
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TO P I C S C O V E R E D
• Definitions of Substance Abuse
• Magnitude of the Problem
• Risks and Benefits of Substance Use
• Identifying Substance Abuse Disorders
• Treatment
S U B S TA N C E A B U S E I N
O L D E R A D U LT S
• In older adults, negative health consequences of
alcohol, psychoactive medications, illicit drugs, and
nicotine have been demonstrated at consumption
levels previously thought of as light to moderate
• Older adults are particularly vulnerable to the
cognitive and physical effects of these substances
• Treatment leads to reductions in substance use
and improvement in general health
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S U B S TA N C E D E P E N D E N C E
• Any use that imparts significant disability and
warrants treatment
• Older problem drinkers are identified less often
by clinicians and are less often referred for
treatment than are their younger counterparts
 Many older people drink at home alone
 Many disorders caused or affected by
substance misuse are common disorders in
late life
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AT- R I S K U S E
• Any use of a substance at a quantity or frequency
greater than a recommended level
 For instance, the recommended upper limit of
alcohol consumption for older adults:
 No more than 1 standard drink per day
 No more than 2 episodes of binge drinking (≥4
drinks/day) in a 3-month period
• Any drinking while on certain medications
• Any drinking with certain medical problems
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PROBLEM USE AND LOW-RISK USE
• Problem substance use—consumption of any
amount of an abusable substance that results in
at least one problem
 For example, use of benzodiazepines by a
patient who has an unsteady gait
• Low-risk or moderate use—that which falls within
the recommended guidelines for consumption
and is not associated with problems
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ABSTINENCE
• Person consumed no alcohol in the previous year
• Obtain history of past use
• Determine reason for abstinence:
 Recent illness
 Lifelong pattern
 Previous history of abuse
 May require preventive monitoring
 Patient may be at risk of mental health problems
ILLICIT DRUG USE AMONG
O L D E R A D U LT S
A study in the general
population found that 2.88%
of older men and 0.66% of
older women had a lifetime
history of illicit drug use
A more recent study of older adult
veterans found 25% had a
primary drug problem or
concurrent drug and alcohol
problems
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O L D E R A D U LT S O F T E N
TA K E A B U S A B L E M E D I C AT I O N S
100%
80%
60%
Do not use
Use
40%
20%
0%
Analgesic
CNS medication Benzodiazepine
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I N A P P R O P R I AT E U S E
O F M E D I C AT I O N S ( 1 o f 2 )
• Many medications used by older people have
the potential to induce:
 Tolerance or withdrawal syndromes
 Harmful medical consequences such as
cognitive changes, kidney disease, falls,
and liver disease
• Often misused: sedatives, hypnotics,
analgesics, diet aids, decongestants, and a
wide variety of OTC medications
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I N A P P R O P R I AT E U S E
O F M E D I C AT I O N S ( 2 o f 2 )
• Monitor medication use carefully
• Avoid prescribing:
 Potentially hazardous combinations of
drugs
 Medications with a high risk of adverse
effects
 Ineffective or unnecessary medications
• Reevaluate use every 3–6 months
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USE OF ALCOHOL
BY OLDER ADULTS
Studies have reported a range of:
• 2% to 4% for alcohol abuse
• 3% to 9% for heavy drinking
• 10% to 22% for daily drinking
• 31% to 58% for abstinence
Alcohol abuse
Heavy drinking
Daily drinking
Abstinence
0%
20%
40%
60%
80%
100%
C U LT U R A L A N D D E M O G R A P H I C
FA C TO R S I N S U B S TA N C E U S E
• The prevalence of alcohol-related problems is much
higher for older men than for older women
 Among younger adults, more women are presenting
for treatment
 Similar patterns are seen with illicit drug use, except
that benzodiazepines are much more commonly used
by older women than by older men
• Conclusions are less clear from the few studies
addressing the effect of ethnicity
 Risk factors more relevant than ethnicity are increased
leisure time and higher disposable income
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P R E VA L A N C E I N
CLINICAL SETTINGS
• Prevalence rates of alcohol problems in hospital
populations are substantially higher than for
community dwellers
• High prevalence rates for problems related to
drinking are becoming more common in
retirement communities
• Data from a Veterans Affairs nursing home
demonstrated that 35% of the patients
interviewed had a lifetime diagnosis of alcohol
abuse
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BENEFITS OF ALCOHOL
CONSUMPTION
• Moderate alcohol consumption among
otherwise healthy older adults has been
promoted as having beneficial effects:
 Reduced cardiovascular disease
 Relaxation and reduced social anxiety
• Recommending drinking to people who
currently do not drink is not advocated
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R I S K S A S S O C I AT E D W I T H
S U B S TA N C E A B U S E
• Excess physical disability
• Mental health problems
• Social and relationship problems
• Economic problems
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EXCESS PHYSICAL DISABILITY
F R O M S U B S TA N C E A B U S E ( 1 o f 2 )
• Consumption > 1 drink/day:
 Increased risk of stroke caused by bleeding
 Impaired driving skills
 Increased rate of injuries such as falls,
fractures
• The risk of breast cancer in women who
consume 3–9 drinks/week is ~50% over that
of women who have <3 drinks/week
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EXCESS PHYSICAL DISABILITY
F R O M S U B S TA N C E A B U S E ( 2 o f 2 )
• Greatest risk: Older adults who have an average of
>4 drinks/day or a diagnosis of alcohol dependence
• Most common physical problems associated with
alcohol dependence:




Alcoholic liver disease
Chronic obstructive pulmonary disease
Peptic ulcer disease
Psoriasis
• Unexplained multisystem disease  probe closely
for alcohol use
INTERACTIONS BETWEEN
A L C O H O L A N D M E D I C AT I O N S
Potential harmful interactions occur between
alcohol and both prescription and OTC
medications:
• Special concern: psychoactive medications such as
benzodiazepines and antidepressants
• Alcohol is also known to interfere with the
metabolism of many medications, including digoxin
and warfarin
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M E N TA L H E A LT H P R O B L E M S
• Older adults with alcohol abuse/dependence are
nearly 3 times more likely to have a lifetime
diagnosis of another mental disorder
• Alcoholism has been implicated in:





Mood disorders
Suicide
Dementia
Anxiety disorders
Sleep disturbances
• Comorbid depression and alcohol use: abstinence
 better depression outcomes
A L C O H O L - R E L AT E D D E M E N T I A
(1 of 2)
• Patients with alcohol-related dementia who
become abstinent do not show a progression in
cognitive impairment comparable to that of
people with Alzheimer’s disease
• Alcoholism is known to lead to a syndrome of
dementia independently
 Interesting new hypotheses implicate
glutamatergic toxicity, but the mechanisms are
not well understood
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A L C O H O L - R E L AT E D D E M E N T I A
(2 of 2)
• Criteria for alcohol-related dementia:
 Clinically evident dementia ≥60 days after last drink
 History of significant use for at least 5 years, ie, ≥35
drinks/week for men and ≥28/week for women
 Occurrence of this period of significant use within 3 years
of the onset of cognitive deficits
• Supporting clinical features:
 End-organ damage
 Cognitive stabilization or improvement after abstinence
 Evidence of cerebellar atrophy in brain imaging
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IDENTIFYING
S U B S TA N C E U S E D I S O R D E R S
• Clinical examination is the most valuable tool
• Screening instruments help increase the
sensitivity and efficiency of the diagnosis
• Laboratory testing: Any combination of
macrocytic anemia, thrombocytopenia, and
elevated γ-glutamyl transferase  further
screening
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THE AUDIT-C
• Q1: How often did you have a drink containing alcohol
in the past year?
• Q2: How many drinks did you have on a typical day
when you were drinking in the past year?
• Q3: How often did you have 6 or more drinks on one
occasion in the past year?
• AUDIT-C is a highly sensitive screen for at-risk
drinking and alcohol dependence and is preferred over
the CAGE questionnaire (next slide)
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THE CAGE QUESTIONNAIRE
C Have you ever tried to Cut down on your
drinking?
A Have you ever gotten Annoyed at someone
for criticizing your drinking?
G Do you ever feel Guilty about your drinking?
E Have you ever had an Eye-opener to steady
your nerves or get rid of a hangover?
A positive answer to one or more questions suggests
problem drinking. CAGE is highly sensitive for alcohol
dependence but not for at-risk drinking.
T R E AT M E N T E N G A G E M E N T A N D
T R E AT M E N T O P T I O N S ( 1 o f 2 )
• The most important aspect of treating an older adult
who is misusing a substance is to engage the
patient in the intervention
• The spectrum of interventions:
 Prevention and education for people who are
abstinent or low-risk drinkers
 Minimal advice or brief structured interventions for atrisk or problem drinkers
 Formalized alcoholism treatment for drinkers who
meet criteria for abuse or dependence
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T R E AT M E N T E N G A G E M E N T A N D
T R E AT M E N T O P T I O N S ( 2 o f 2 )
• The array of formal treatment options:
 Psychotherapy
 Education
 Rehabilitative and residential care
 Psychopharmacologic agents
• Older adults engaged in treatment have been
shown to have very robust improvement,
especially in comparison with younger cohorts
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B R I E F I N T E RV E N T I O N S
• Low-intensity, brief interventions are cost-effective,
practical approaches to at-risk and problem drinking
• 2 randomized, controlled trials of advice protocols in
primary care settings showed that:
 Older adults can be engaged in brief intervention
protocols
 The protocols are acceptable to this population
 There was a substantial reduction in drinking among
the at-risk drinkers receiving the interventions
compared with a control group
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O U T PAT I E N T M A N A G E M E N T
• For older adults, peer-specific group activities are superior
to mixed-age group activities
• Outpatient rehabilitation usually needs to address issues of
time management
 Abstinence reduces the time spent in maintaining the
substance-use disorder
 Management of this time, which is often the greater part of a
patient’s day, is critical to the prognosis
• Commend patients for cutting down on use as well as for
stopping—especially with medications such as
benzodiazepines
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A L C O H O L W I T H D R AWA L
• Early symptoms: tachycardia, diaphoresis,
tremulousness, and hypertension
• May progress to overt delirium, psychosis, seizures
• Interventions:
 Oral benzodiazepine is the most common intervention
 IV lorazepam (off-label), followed by oral taper, is the
most expedient intervention
 Carbamazepine (off-label) evidence suggest this is as
effective as a benzodiazepine
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I N PAT I E N T D E TO X I F I C AT I O N
• Consider for patients with severe
dependency, withdrawal potential, or
significant medical or psychiatric comorbidity
• To achieve detoxification:
 Place the patient on the minimum amount of
drug that suppresses withdrawal symptoms
 Decrease dosage by 10% every 3 half-lives
 Provide supportive counseling via groups,
psychosocial support, and 12-step programs
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PHARMACOTHERAPY (1 of 2)
• The use of medications to support abstinence may
be of benefit, but it is not well studied
 Small-scale studies have demonstrated that naltrexone
is well tolerated and efficacious in older patients
 SSRIs and other antidepressants are not effective at
reducing alcohol use in younger persons but can be
effective in treating depression in some with both
alcohol addition and depressive disorder
• Comorbid medical and psychiatric disorders must
be identified and properly treated
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PHARMACOTHERAPY (2 of 2)
Some of the general principles used in treating
younger patients can be applied:
• Benzodiazepines are important in the treatment of
alcohol detoxification, but they have no clinical place
in maintaining long-term abstinence
• Disulfiram may benefit well-motivated patients, but
cardiac and hepatic disease limits its use by the
older person
• Older patients can be initiated and maintained on
methadone following the same principles of use as
in younger patients
E S TA B L I S H I N G A B S T I N E N C E
FROM NICOTINE
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• Pharmacologic substitution with either nicotine gum or
patch is followed by a gradual decrease in dosage
• In several trials, antidepressants improved rates of
continued abstinence, but only bupropion is FDAapproved for this purpose
• Varenicline is also FDA-approved but there is a black-box
warning because of neuropsychiatric symptoms, such as
depression and suicidality.
• Psychotherapy plus pharmacotherapy is better than
pharmacotherapy alone
Slide
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GAMBLING
• Older adults who engaged in problematic and
compulsive gambling behaviors earlier in life
often continue this pattern of destructive
behavior
• Ask about problematic gambling during history
taking
 Screen for alcohol abuse, smoking, other substance abuse
• Refer to community resources and 12-step
programs
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S U M M A RY ( 1 o f 3 )
• Older adults are particularly vulnerable to the effects of
alcohol, psychoactive medications, illicit drugs, and
nicotine
• Misuse of prescription and OTC medications is
common among older adults
• The clinical examination is the most valuable tool in
identifying substance-use disorders
• Cognitive impairment from chronic alcoholism in the
older adult may improve with sustained abstinence
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SUMMARY (2 of 3)
• Older adults involved in treatment have very robust
improvement, especially compared with younger
cohorts
• In randomized, controlled trials, brief counseling
interventions were efficacious in substantially reducing
problem drinking
• Clinicians should be vigilant for signs of alcohol
withdrawal in older people hospitalized for elective
surgery or a condition unrelated to substance abuse
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S U M M A RY ( 3 o f 3 )
• Addiction treatment is not “one size fits all.” There
are many options—use them.
• Compliance with treatment is important. The next
contact is the most important part of the session.
• Treatment is not a “carve out” available only in
select settings
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CASE 1 (1 of 4)
• An 82-year-old woman comes to the office to establish
care. She is accompanied by her daughter, who is
concerned that her mother’s use of diazepam is related
to recent falls and problems with balance.
• History includes osteoporosis and knee osteoarthritis.
Medications include alendronate, calcium,
acetaminophen, and diazepam.
• The patient has been taking diazepam for many years,
usually 10 mg q8h. She acknowledges having felt
stressed during much of her life but says she is not
anxious or depressed now.
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CASE 1 (2 of 4)
• On examination, vital signs are stable, and there are no
orthostatic changes in blood pressure. There is some
bruising on her elbows and hips, and osteoarthritic
changes are noted in both knees.
• There is no evidence of delirium or cognitive impairment.
• Her gait is somewhat slow, and she needs to take a
couple of steps to make a 180-degree turn. She describes
some bilateral knee pain when she rises. She can remain
in semi-tandem stance for <10 sec and cannot perform a
tandem stance.
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CASE 1 (3 of 4)
Which of the following is the most appropriate first step in
addressing the patient’s benzodiazepine use?
A. Refer patient to residential treatment program.
B. Refer patient for psychiatry consultation.
C. Recommend gradual taper of the benzodiazepine
dosage.
D. Recommend switch to a shorter-acting
benzodiazepine.
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CASE 1 (4 of 4)
Which of the following is the most appropriate first step in
addressing the patient’s benzodiazepine use?
A. Refer patient to residential treatment program.
B. Refer patient for psychiatry consultation.
C. Recommend gradual taper of the benzodiazepine
dosage.
D. Recommend switch to a shorter-acting
benzodiazepine.
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CASE 2 (1 of 2)
A 73-year-old man comes to the office for a routine
physical examination. He is in good health and takes no
medications. He drinks alcohol daily but has no history of
an alcohol use disorder.
Which one of the following is within the daily limit for this
patient?
A. One 1.5-oz glass of whiskey
B. One 8-oz glass of wine
C. Two 12-oz beers
D. One 4-oz glass of sherry
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CASE 2 (2 of 2)
A 73-year-old man comes to the office for a routine
physical examination. He is in good health and takes no
medications. He drinks alcohol daily but has no history of
an alcohol use disorder.
Which one of the following is within the daily limit for this
patient?
A. One 1.5-oz glass of whiskey
B. One 8-oz glass of wine
C. Two 12-oz beers
D. One 4-oz glass of sherry
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CASE 3 (1 of 3)
• An 80-year-old previously independent man is
evaluated because of lethargy with periods of severe
agitation. Two days ago he had elective knee
replacement, during which he lost ~500 mL of blood.
• History includes hypertension controlled with
hydrochlorothiazide. He drinks alcohol socially.
• On examination, the patient is distracted and
disoriented and picks at his clothing. Temperature is
37°C (98.7°F), BP is 170/84 mmHg, heart rate is 110
bpm and regular, and respiratory rate is 14 breaths per
minute. The surgical site is clean and dry, and lab
results are unremarkable.
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CASE 3 (2 of 3)
Which one of the following is the most likely cause
of this patient’s agitation?
A.
B.
C.
D.
Alcohol withdrawal syndrome
Hypertensive encephalopathy
Blood loss
Underlying dementia
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CASE 3 (3 of 3)
Which one of the following is the most likely cause
of this patient’s agitation?
A.
B.
C.
D.
Alcohol withdrawal syndrome
Hypertensive encephalopathy
Blood loss
Underlying dementia
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GNRS4 Teaching Slides Editor:
Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF
GNRS4 Teaching Slides modified from GRS8 Teaching Slides
based on chapter by
David W. Oslin, MD and Donovan Maust, MD
and questions by Alison Moore, MD
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2014 American Geriatrics Society